HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 31 JAY ROAD 8/13/2024 Commonwealth of Massachusetts (^;; "` °
19 S City/Town of
System Pumping Record t
Form 4 e � toe\
DEP has provided this form for use by local Boards of Health, Other fiftgi 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 -he pumping date in
accordance with 310 CMR 15.351.
HOUSE: front back side rear le righ
A. Facility Information BUILDING: back side rear left rig t
Important:when DECK: under
filling out forms 1. System Location:
on the computer, t
use only the tab -3 1 \`
key to move your Addressl�
cursor-do not ! � !1_�Q�i� _ MA 0 (9- �S
use the return Cit !Town ` _
key. y State Zip Code
2. System Owner:
rd
Name
reran
Address (if different from location)
MA
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
i, Date of Pumping 2, Quantity Pumped: »G
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): -- ---
4, Effluent Tee Filter present? Ye Wo If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pu ped:
6. System Pumped By:
Dave Tiney Mass 1AA95V Mass 1AD31
Name Vehicle License umber
Bateson Enterprises, Inc.
Company
7. on where contents were disposed:
GLS
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc, 11112 System Pumping Record-Page 1 of 1