HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 99 HAY MEADOW ROAD 7/1/2024 �a°yet
Commonwealth of Massachusetts
City/Town of .gyp'1a�
- ol�p1.
a System Pumping Record
�� tt
Form 4
DEP has provided this form for use by local Boards of Health. Other forms l� ed, but the
information must be substantially the same as that provided here. Befort(Wethis 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 back side ear left'�right
A. Facility Information BUILDING: front back rear left rigTit
Important:when DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab C.'i
key to move your Addres
cursor-do notuse the return N, ,�� MA
key. CitylTown State Zip Code
2. System Owner:
r� n
Name
low
Address (if different from location)
__ _ MA
City/Town State
Zip Code
_ Telephone Number
B. Pumping Record
1. Date of Pumping L �5W
p 9 Date I 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
9 ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed conditi n of component pumped:
6. System Pumped By
Dave Tiney Mass 1 AA95E Mass 1 A 31
Name Vehicle License N mber
Bateson Enterprises, Inc.
Company
7. ion where contents were disposed:
OGLSD
C, I��-IZ�
Signature of Hauler Date
Signature of Receiving Facility(orattach facility receipt) Date
l5form4.doc• 11112 System Pumping Record•Page 1 of 1