HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 79 TUCKER FARM ROAD 12/22/2025 _ Commonwealth of Massachusetts
=F'- City/Town of
a 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, - ____,_
_ HOUSE: front ac side rear eft right
A. Facility information BUILDING: front back side rear left right
Important;When
DECK: under
felling out forms 1, System Location:
on the computer,
use only the tab
key to move your Addr s
cursor-do not MA .
use the return ---__...
key. Cityr own State Zip Code
"� rya
2. System Owner:
ame
r
Address (if different from location)
y.; MA
City/Town State Zip Code
Telephone Number
B. Pimping Record
w.-_----- --. _------ _.
1. Date of Pumping _--- --- ?. Quantity Pumped:
Date Gallons
3. Component: ❑ 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:
DaveTlne - 71ass 1AA95 Mass 1AD31Z_
Name Vehicle t_ic0n urnber �
Bateson Enterprises, Inc. "
Company
7. Location where contents were disposed:
GLSD
!2121
Si ature Hauler Date
Signature of Receiving Faciloty(or attach facility receipt) Date
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