HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 143 DUNCAN DRIVE 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 CIVIR 16.351,
HOUSE: front ide rea left, right
'e
A. Facility Information BUILDING: front qbac --side rear ;e:�right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not 0 (�A. MA
use the return City/Town State Zip Code
key.
2. System Owner:
C, -------
Name
Address(if different from location)
MA
City(Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ------- 2. Quantity Pumped:
DateGallons
3. Component: Cesspool(s) Septic Tank ❑ Tight Tank 7 Grease Trap
F-1 Other (describe):
4, Effluent Tee Filter present? es E No If yes, was it cleaned? Yes F No
5, Observed con itio� of com anent pumped:
6. System Pumped By:
pave-�In Mass `IAA95E/-� Mass 1AD31Z
------- .Vehii—cleEt�en
Name
Bateson Enterprises,
Company
r 71
ILI
(o r-
7. ti n where contents were disposed:
LSD
§ig—na�-ture df Hauler Date
Signature of Receiving Facility(or aktach facility receipt) Date
t5form4.doc- 11/12 System Pumping Record -Page 1 of 1