HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 719 JOHNSON STREET 5/31/2022 Commonwealth of Massachusettsi�cEwEU
w City/Town of 311021
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System Pumping Record MA PNDo�Ea
Form 4 ?CwpIHOE
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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, Left5l1lkht side of house nder Deck
Important:When
filling out forms 1. System Locatio - eft f Right side of building, Left/Right front of building, Left/Right rear o building,
on the computer, / ,_ ,�
use only the tab (((NNIINNiTTN!•((�
key to move your A;M�o
L// i� /
cursor-do not MA
use the return key. City/Town State Zip Code
2. System Owner:
Name
ietxn
Address(if different from location)
_ MA
City/Town State 9 f Zip Code
Telephone Number
B. Pumping Record A&�
1. Date of Pumping -date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) *Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): — - --- - - —
4. Effluent Tee Filter present? ❑ Yes,�YNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass F5821 _
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Lo . n ere contents were disposed:
GL
Signature of Haule Date
Signature of Receiving Facility(or attach facility receipt) Date
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