HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 66 MARIAN DRIVE 8/26/2024 .,41
Commonwealth of Massachusetts
City/Town ofT
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms maybe 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 sid rea left ight
A. Facility Information BUILDING: front back side r left right
Important:when DECK: under
filling out forms 1. S t m Location:
on the computer,
use only the tab
key to move your Wdess
cursor-do not ' �� MA0/P
use the return Cll !Town
key. y State Zip Code
2. S em Owner:
IQ
nrWn
Address (If different from location)
MA
City/Town State rode
_ Telephone Number
B. Purnping Record
)5co
1. Date of Pumping ate 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Ye No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E ss 1AD31Z
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. a I where contents were disposed:
;D)'
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1