HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 11 TANGLEWOOD LANE 11/21/2025 Commonwealth of Massachusetts
cz_- 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,
left rig
A. FacilityInformation -_--- --- --_—__ - �u�Di G front back side-_r . left--rir, r
e g
important:When DECK: under
filling out.forms 1. System Location:
on the computer,
use only the tab
---._ _._._ ._ ----— ------ -
_._...___..
key to move your Address
cursor-do not MA
use the return --- -------- r -= -
—�1� ------ -------- --— --
key, Clty/Town State, Zip—Code ------------.._..
2. S Owner:
• ' Na e
4
Address(if different from location)
MA
City(Town Stat e
-
Telep o�ie Number
B. Pumping Record — - --_---- -_-_ __.
1, Date of Pumping
Date--- ---�.— 2. Quantity Pumped: Ga--- -------.___.._
Mons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): P40 If
4. Effluent Tee Filter present? ❑ Yes Poo If yes, was it cleaned? ❑ Yes 0 No
5. Observed condition of cam po ent ump
7
6. System P"' ped By:
Dave T I n_e _ _ -------------__ __-- Mass 1 AA9 5 E Mass 1 AD ,1 Z
ame Vehicle License Nur er — --"
136-t�on Enterprises, Inc
npany
7. Lo ation wh re runts were dispesed:
GLSD
Signature of Hauler Date
— -- - ——--
Signature of Receiving Facility(or attach facility receipt) Date -"' — ----"-------
t5form4.doc• 11/12
System Pumping Record •Pale 1 of 1