HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 481 REA STREET 4/19/2022 Commonwealth of MassachusettsECEtvEv
City/Town of
y ApR 19 2022
System Pumping Record
Form 4 OF NvEYH TMEW
1OHSXL pEPAR
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.
A. Facility Information
Left/Right front of house, Left/Right rear of house, Le Right side of house, Under Deck
Important:When
filling out forms 1. Syste Location: Left/Right side of building, Left/Right front of building, eft/ ig rear f building,
on the computer,
use only the tab
key to move your 7e'�L(
/
cursor-do not cj f� � MA
use the return City/Town State Zip Code
key.
2. System Owner:.
Name
ream
Address(if different from location)
MA
City/Town State 9 Zip Code
Telephone Number
B. Pumping Record
_�7_1. Date of Pumping ate 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Ye No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
)OKM114 -- -
6. System Pumped By:
Dave Tiney Mass F5821
Name vehicle License Number
Bateson Enterprises, Inc. _
Company
7. Lo ere contents were disposed:
GLS
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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