HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 96 SUGARCANE LANE 6/10/2024 '�'� 4�
Commonwealth of Massachusetts ��°`��
w City/Town of
V ��N 2024
° System Pumping Record
Form 4 ..q, 1
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
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: ron back side rear left righ
A. Facility Information BUILDING: front back side rear left right
Important:when DECK: under
filling out forms 1. System Location:
on the computer, CG use only the tab S4y�ec�� �n
key to move your Address V
cursor- not A )+ A _
use the return
Iv urn rt�n MA
key. CilylTown State Zip Code
2. System``O�ner:
c.Y roan
eA
Name
rrum
Address (if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dab 3 2. Quantity Pumped: S�
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 condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E 4gass 1AD
Name Vehicle license Numb
Bateson Enterprises, Inc.
Company
7. oh where contents were disposed:
G L S
Or
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11112 System Pumping Record•Page 1 of 1