HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 SHANNON LANE 3/21/2025 Commonwealth of Massachusetts ®
=r r City/Town of pit
nd®
r
S stem Pum in c�
� c Q�^Re r '
Y �
Form 4 Apt
er 2 2025
DEP has provided this form for use by local Boards of Health. O s may be used, but the
information must be substantially the same as that provided here. s this form, check with your
local Board of Health to determine the form they use The system Purnping P�C*Ijt, I t be SUbmltted la
the local Berard of Health or other approving authc[ity within 14 days from the purnpinr Olt[)
accordance with 310 CMR 15.351. _
---------- HOUSE: front a c k side rear eft r i h
A. Facility information BUILDING: ront back side rear left riffht
Important:When
DECK ncler
filling out forms 1. Systern t._ocation�.
on fhe computer, P W_
use only the tab __ ' ._ /tc +� _ ✓\
key to move your Address
cursor-do not
use the return - -` _ _ —` —_—_---.________,.________..__ MA-- -- ___
key. City/Town State Zip Code
2, System Owner:
N7me
raarn�l' `V
Address (if different from location)
MA
_ ------- -------_.---_
City/Town state Gip Code
Teiephone Number
�. Purnping Record
1. Date of Pumping _ Lw�i.._-__.___. 2 Quantity Pumped f .___...__.._._.__...--
Date Gallons
3, Component: ❑ Cesspool(s) Septic Tank C] 'Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee filter present? (D 'Yes ( ] No If yes, was it cleaned? Yes [] No
5. Observed condition of component pumped;
ryry S5U(_ k
6. Systern Pumped By.
Dave TIneY Mass 1 9 Mass '1AD31Z
Name VoInIcle Licenses N iber
Bafeson Enferprises, Inc_
Company
T tian where contents were disposed,
GLS
Signature of Hauler Oate
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc- 11112 Systern Pumping Record 'Page 1 of 1