HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 131 GRANVILLE LANE 12/2/2024 Commonwealth of Massachusetts
z 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(si Derear(I�' right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab t I
key to move your Address
cursor-do not
use the return I-)�6 MA
key. City/Town State Zip Code
2. System qwner:
tow)
Address(if different from location)
MA
CityrTown State Wz Zip Code
Telephone Number
B. Pumping Record
Is-ce)
1. Date of Pumping oat 17 b 2. Quantity Pumped'.
- Gallons
3. Component: ❑ Cesspool(s) Septic Tank 7 Tight Tank F7 Grease Trap
0 Other (describe):
4. Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? F Yes E] No
5. Observed concli 'on of component Pumped:
6. System Pumped By:
Dave TIney Mass 1AA95E --M`ass1�`D31z-)
Name Vehicle License Nunr(ber_® ,„, �
Bateson Enter rises, lnc.
Company
7. Ct n where contents were disposed:
L Si
Signature of Hauler Date
_Signature of Receiving Facility
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