HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 173 BRIDGES LANE 7/1/2024 P�ao�et
Commonwealth of Massachusetts
City/Town of
a System Pumping Record
Forrn 4
DEP has provided this form for use by local Boards of Health, Other forms m y be used, but the
information must be substantially the same as that provided here. Before usl 1 `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: prontback side rear left fight
A. Facility Information BUILDING: back side rear left right
DECK: under
Important;When
fllling out forms 1. System Loca tign: ��
on the computer, CI
use only the tab
key to move your Addr ss
cursor-do not .�(\(S LPr/1- MA
use the return Cityrrown State Zip Code
key.
2. System Owner:
lob
f-er _ 2l� ►crn c.
Name
num
Address (if different from location)
MA
Clty/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 No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed conditio of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E Mass 1AD31
Name Vehicle License Nu ber
Bateson Enterprises Inc.
Company
7. n where contents were disposed:
LSD
1
Signature of Hauler Date
Signature of Receiving Facility(orahach facility receipt) Date
l5form4.doc• 11112 System Pumping Record •Page 1 of 1