HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 439 WINTER STREET 5/10/2022 Commonwealth of Massachusetts RECENED
= City/Town of MAY 10 Nzz
System Pumping Record
Form 4 TOWN OFH oij M N'T
w, tiEALT
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 you
local Board of Health to determine the form they use. The System Pumping Record must be submitted b
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information HOUSE: front back side qilefto
Important:When BUILDING: front back side rear left
filling out forms 1. System Location: DECK: under
on the computer, Q �Q �
use only the tab ✓� �,✓t'n� J - ----- -
key to move your Address
cursor-do not (, L _
use the return ityfrown 6=?bR 1' —4 Z49L
key. Slate Zip Code
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2. System Owner:
Name
ream
Address(if different from location)
CityTTown State Zi Code oc"03— '26f—
Telep one Number
B. Pumping Record /RXJ
1. Date of Pumping 2. 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:
---------— --- n �
6. System Pumped By:
Dave Tiney -_ m `_ Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loc where contents were disposed.
L
Signature of Hauler Date—�—