HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 LOST POND LANE 7/29/2024 Commonwealth of Massachusetts
City/Town of _
a ° System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other fbrrrls 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 back si rear left righ
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 q) COS f pf►
key to move your Address
cursor•do not /V nC'sIR� MA Q 4 FScI�
use the return Cil frown
key. y Slate Zip Code
2. System Owner: I
rd Q6' „n(( y,e
Name
rnwn
Address (if different from location)
MA
Cltyfrown Stale Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping —a f2 2. Quantity Pumped:
Date 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 condition of component pumped:
k34fr-,� l
6. System Pumped By:
Dave Tiney Mass 1AA95E ass 1AD342,
Name Vehicle License Numb
Bateson Enterprises, Inc.
Company
7. Loca ion where contents were disposed:
GLSD
c k b y
Signature of Hauler Date
Signature of Receiving Facility(or,attach facility receipt) Date
l5form4.doa 11112 System Pumping Record •Page 1 of 1