HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 131 GRANVILLE LANE 12/15/2025 Commonwealth of Massachusetts
u - 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
focal Board of Health to determine the form they use. fihe System Pumping Record r-nust be submitted to
the local Board of Heaith or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15,351
HOUSE: front bac side rea Qleright
A. Facility Information BUILDING: front back side rear left rlpht
Important:When DECK: Under
Wiling out forms 1. System Location:
on the computer, /r^�y
use only the tab _.'az__.w s!1-41
key to move your Address
cursor-do not Altyro.
use the return _ . 0— __—_------_. .__-__-__ ___.__ MA _ ---- _-__._.----key. wn State Zip Code
2. System Owner:
IV/Lll�
r
ddress (if different from location) ---
-------- MA
it !Town
y State Zip Code
�
-Z VR-.s
Telep m hone Nuer
B. Pumping Record _._____-_-_-------
1. Date of ln Pum ---ate .- .__._... CJ
p 9 G 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
0 Other (describe) — _--- -— - --------- --- -------- -.� --- -----
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? [I Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By: ------
DaveTlney` ------- -- --------------------.______-_._--- _Mass 1AA93(�'E ass 1AD31Z
Name Vehicle License Numbe
Bateson Enterprises, Inc. _
Company
T k'onwhere contents were disposed:
GLi ler _
Date -
Signature of Receiving Facility (or attarh facility r�eeipt? date ----- _______.__
t5form4.doc, 11t12
System Pumping Record -Pale 1 of 1