HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 92 BRIDGES LANE 5/24/2024 Commonwealth of Massachusetts Ando�et
City/Town of down of�e
System Pumping Record
Form 4 MAY 4 2024
�M J'
DEP has provided this form for use by local Boards of Health. Other forms may be used, but tweht
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351. --
HOUSE: front ack side read left right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, q
use only the tab
key to move your Address
cursor-do not P .�l�.� MA 0 (�s`f S
use the return City/Town State Zip Code
key.
2. System Owner:
,� 1 12ac�re- CjectiU
Name
rerun
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping S/2 Z F 2. Quantity Pumped: �S
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condi ion of component pumped:
V0(`I
6. System Pumped By:
Dave Tiney Mas rlAA9�5E Mass 1AD31Z
Name Vehicl License N ber
Bateson Enterprises, Inc.
Company
7. ion where contents were disposed:
GLSD"_�o<
_ —
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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