HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 ROCKY BROOK ROAD 6/17/2024 �LN Commonwealth of Massachusetts 10 0
City/Town of UN 1 ti024
a 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-datein
accordance with 310 CMR 15.351.
HOUSE: front ba k side rear le =right
A. Facility Information BUILDING: front back a rear left right
DECK: under
Important:When
filling out forms 1. Sys em Location:
on the computer, e(flo f 9 D
use only the tab l�Y\ tJ ,,ee/n�( �f key to move your Address, H4 No��--k
Nq
cursor-do not MA
use the return City/Town State State Zip Code
key.
2. S tem Owner:
rf9go-�
Name
ienm
Address(if different from location)
MA
City/Town State � Q �ip Code
Telepho a Rur&er
B. Pumping Record
of Pumping 2. Quantity Pum ed: 1
1. Date p 9 Date y p Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): — — --
4. Effluent Tee Filter present? ❑ Yes to If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component p ped:
6. System Pumped By:
Dave Tiney Mass 1AA95E Mass 1AD31Z
Name Vehicle LicensqNtr6ber
Bateson Enterprises, Inc.
Company
L
Lo t' where contents were disposed:
GLS — --- ---
Signature of Ha ler Date
Signature of Receiving Facility(or attach facility receipt) Date
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