HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 89 LOST POND LANE 10/24/2025 12\- Commonwealth of Massachusetts Town Of 'mover
----r City/Town of OCT
System Pumping Record 2025
M.�,wf Form 4 Hea/th De,gy
p
DEP has provided this form for use by local Boards of Health. Other forms may be u M
information must be substantially the same as that provided here. Before using this form, cheMk 47th 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 CIVIR 15.351.
ack side rear left right)
HOUSE: front�
A. Facility Information BUILDING: ro ni back side rear left right
DECK: under
Important:When
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
key. City/Town State Zip Code
2. S t Owner:
,n77ti
Name
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1, Date of Pumping Date 2. Quantity Pumped: Gallons
3, Component: ❑ Cesspool(s) Z-4319`ptic Tank 7 Tight Tank 7 Grease Trap
[] Other (describe):
4. Effluent Tee Filter present? 7 Yes If yes, was it cleaned? ❑ Yes f7 No
5. Observed condition of component pumped,
6. stem limped By:
Dave T T,
I Mass 1AA94 Mass 1AD31Z
�N a—me --, Vehlcle License NtxDer -.
B,ateson,,Enterprises, Inc.
-C�O-mFpany
7. _LSD
he contents were disposed:
-----------
'Signature'-o—fHauler --
facility receipt) Date
Signature C�11�Ig Facility
(1�ra attach R f
t5form4.doc- 11/12 System Pumping Record-Page 1 of 1