HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 146 RALEIGH TAVERN LANE 6/10/2024 Commonwealth of Massachusetts
_ City/Town of
System Pumping Record
Form 4
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: front 0side rear 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, r,f� �
use only the tab (7fp eratYt fac�e�/�
key to move your Ad res
cursor-do not MA l (0
use the return key. CityfTown State Zip Code
2. System Owner:
Name
Address(if different from location)
MA
Clty/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date ?b-LZ 2. Quantity Pumped:
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 con ition of component pumped:
OrP4
6. System Pumped By:
Dave Tiney Mass 1AA95E X<ass 1AD31Z
Name Vehicle License Nu ber
Bateson Enterprises, Inc.
Company
7, nocon where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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