HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 116 BRIDGES LANE 12/19/2024 Commonwealth of Massachusetts
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System Pumping Record
~�`` 72025
Form 4
DEP has provided this form for use by local Boards ofHealth. Other
—' ftent the
information must be substantially the same as that provided hare. Before using this form, check with your
local Board of Health Uo determine the form they use. The System Pumping Record must be submitted to
the |Doa| Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31UCIVIR 15,351
HOUSE: Cfr:ont ack side rear left 194
)�) C
A. Facility Information BUILDING: front back side rear left right
� under
Important: DECK:� ��0e^
filling out forms 1. System Location-,
on the computer,
use only the mu /x
key to move your *uu4ou ~�
cursor_do not
MA
use the return
key. `'` '—'' ~`^'` Zip Code
2. System Owner:
Name
Address(if different from location)
MA
C|tyfTown State Zip Code
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped'. Gallons
3. Component Cesspool(s) Septic Tank Tight Tank Grease Trap
E] Other (describe):
4. Effluent Tee Filter present? [] Yea No If yes, was it cleaned? F� Yes Fl No
5. Observed condition of component puhnped:
G. System Pumped By:
Dave TIney M
Name Vehi be
Bateson FrIterprises, Inc, ------ '
7. disposed:
Signature of Hauler Date
attach facility receipt) Date
of
t5fonn4.dmc- 11/13 System Pumping Record `puqeI of
