HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 60 TIFFANY LANE 10/16/2025 Commonwealth of Mass over
achusetts
f a City/Town of OCT 16 2025
.System Pumping Record
Farm M::"
,_ 4'' ark
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 1 5.351 __-._.
HOUSE: front back side rear Ie i
A. Facility Information BUILDING: front back side rear Vert rifVrt
Important:When DECK: under
filling out forms 1. System Location:
on the computer, -"
use
key to move your Add es _ !__.Y
S
cursor do not
usethe return _.. ✓4 ....__.-_._.__-_-_.__...A—_._._____.._._ __...._._.. M ...._-_-___— ___..........
key.
CitylTown State Zip Code
2, System Owner:
Name
ieru^n
Address (if different from location)
MA
City/7own State Zip Code
..._-------
Telephone Number
B. Pumping Record
1. Date of Pumping f oa 2. Quantity Pumped:( x --_._�_
t I Gallons
3, Component: Q Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
[] Other (describe) -_.__ _._______ .__.__-___ __..._._. .___..._. ._...
4. Effluent Tee Filter present? ❑ Yes [ ] No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tln,ey Mass 1AA95E Mass 1AD31Z
Name Vehicle Licenso �c;r
Bateson Enterprises, Inc.
_ __....__-___.__....._....____.._.....__.....___-_
Compan_-_----y
7. Z Lion where contents were disposed.
GLS
Sign ur of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date -
t5forrn4.doc- 11/12 System Purnping Record -Page 1 of,i