HomeMy WebLinkAboutSeptic Pumping Slip - 145 Crickett - Septic Pumping Slip - 145 CRICKET LANE 10/4/2024 i
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
i
DEP has provided this form for use by local Boards of Health. Other forms 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 15.361. -
HOUSE: front ack side rear left rfgh
A. Facility Information BUILDING: front back side rear left tgt
Important:When DECK: under !
fIIling out forms 1. System Location:
on the computer, c t; � �e C
(� ..
use only the tab �
key to move your Address
cursor-do not n tf— MA
use the return
key, Cityrrown State Zip Code
2. System Owner:
Name
etm �r
Address(If different from location)
MA
CItyrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date / 2. Quantity Pumped: Gatos
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe); —
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4. Effluent Tee Filter present? ❑ YespNo If yes, was It cleaned? [IYes ❑ No
5. Observed condition of component ped;
6. System Pumped By:
Dave Tiney Mass 1AA95E Mass 1AD31Z
Name Vehicle License Num r
Bateson Enterprises, Inc.
Company
7. Loc klon where contents were disposed;
tLS
lU qv
Signature of Hauler Date
Signature of Recelving Facility(or attach facility receipt) Date
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