HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 43 JAY ROAD 1/25/2025 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: rant back side rear 8 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 —143—��—'4❑Z � _..—
key to move your Address
cursor-do not MA
use the return City/Town State Zip Code
key.
2. System Owner:
S tab
Name
Address(if different from location)
MA
City/Town State Zip Code
C'I
Telephone Number
B. Pumping Record
1. Date of Pumping -bate 2. Quantity Pumped. Gallons
3. Component: 7 Cesspool(s) Septic Tank 7 Tight Tank ❑ Grease Trap
F1 Other (describe):
4. Effluent Tee Filter present? E] Yes No If yes, was it cleaned? ❑ Yes 7 No
5. Observed condition of c\nmponent pumped:
6. System Pumped By:
Dave Tiney ass 1AA95E Mass 1 AD31 Z
Mass
Name Vehicle License mber
Bateson Enterprises, Inc.
Company
7. (oc t'on where contents were disposed:
G L11
GLS
Signature of Hauler Date
Signature of Receiving,—Facility(or attach facility receipt) Date
t5forrn4.doc-11/12 System Pumping Record -Page 1 of 1