HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 BANNAN DRIVE 7/1/2024 Commonwealth of Massachusetts C) ��
City/Town of p
a System Pumping Record1 yy`,��,�ti
Form 4
r 4"_
DEP has provided this form for use by local Boards of Health. Other forms l�le 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 Qr other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
HOUSE: fron back side rear eft right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab l�� nnG^
key to move your Addres
cursor•do notuse
e�0(�� MA 0
key the return City/Town State Zip Code
2. Syste( Owner:
LA), C �
Name
imm
Address (if different from location)
MA
Clly/Town State Z Code
Telephone Number
B. Pumping Record y
1. Date of Pumping Date fCL L \ 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
g ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed conditio of component pumped:
6. System Pumped By:
Dave Tiney Ma rsZ951E Mass 1AD31Z
Name Vehic l lcense N tuber
Bateson Enterprises, Inc.
Company
7. ion where contents were disposed:
G L S D)
Signature of Hauler Date
Signature of Receiving Facility(oratlach facility receipt) Date
t5form4.doc• 11112 System Pumping Record•Page 1 of 1