HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 30 SUGARCANE LANE 8/6/2026 Commonwealth of Massachusetts
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 CIVIR 15.351.
HOUSE:rfront)§)ck side rear le
BUI fro n left�rt
A. Facility Info n LDING: ront back side rear
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 City/Town State Zip Code
key.
2. System Owner:
------------
-Name
Address(if different from location)
MA
City/Town 4ry State Zip Code
0 --�
Telep'hone Number
B. Pumping Record
If 5!7
1. Date of Pumping 2. Quantity Pumped: Gallons
3. Component: 7 Cesspool(s) Septic Tank 7 Tight Tank 7 Grease Trap
❑ Other (describe):
4, Effluent Tee Filter present? 7 Yes i No If yes, was it cleaned? El Yes M No
5. Observed condition of component pumped:
-2��r =+--
6. System Pumped By:
Dave Tine______ mass 1 95 Mass 1AD31Z
S S
Name Vehicle License imber
Bateson Enterprises, Inc.
-Company
7, �o L tion where contents were disposes:
GLS ------
f2 c
i- -ature o auler bile
Signature of lkeceiving,Facility(or attach facility receipt) Date
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