HomeMy WebLinkAboutPumping Slip - Septic Pumping Slip - 125 BRIDGES LANE 12/12/2024 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
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 15.351.
HOUSE: front back <s:�ide rear( eft right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab )?'5- 1'-14
key to move your Address
cursor-do not MA
use the return CityfTown State Zip Code
key.
2. System Owner:
VVQ 1 0
Address(if different from location)
Name
MA
City(Town State dip Code
Telephone Number
B. Pumping Record
2. Quantity Pumped,
I, Date of Pumping Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank 7 Tight Tank F7 Grease Trap
[] Other (describe): —------
4. Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? ❑ Yes D No
5. Observed condition of component umped:
6 L JL
GO
6, System Pumped By:
Dave Tlaey Mass 1AA95E (' Mass 1AD31
Name Vehicle License Rum .
Bateson Enterprises,
-C-Om-pin-y-
7. L ation where contents were disposed:
LSD
Signature
Ignature a Hauler Date
--
Signature of Receiving C iliy(0
r attach facility receipt) Date
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