HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 95 CARLTON LANE 6/10/2024 � Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
M
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: fr ack side rear left ri ht
A. Facility Information BUILDING: front back side rear le right
DECK: under
Important:When
filling out forms 1. system OCatl n'
on the computer, V ll L A' I �,Ph
use only the tab III���,,,I"Q f\ d�� "" --
key to move your Address
cursor-do not Y�-z -
key. t Ir� MA ((
use the return City/Town State Zip Code
2. System Owne
ame
Address(if different from location)
MA
City/Town State.
( ® Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped. Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney E�llass 1 AD31 Z
Name :-VEe--hicleL�icenseNumber
Bateson Enterprises, Inc.
Company
7. Loc ' w e contents were disposed:
LSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record.Page 1 of 1