HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 205 GRAY STREET 5/31/2022 riECEIVED
,C'\ Commonwealth of Massachusetts MAY 31 NZZ
City/Town of
o System Pumping Record YOHE LTHpEPAR MENTER
w 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.
A. Facility Information
Left/Right front of house, Left/Right rear of house, Left/Right side of house, Under Deck
Important:When
filling out forms 1. System Location: Left/Right side of building, Left/Right front of building, Left/Right rear of building,
on the computer. S �/p
use only the tab 1/"d'/
key to move your PdEress
cursor-do not Y )6K 0_ _MA t ` 1S y
key.
use the return City/Town State Zip Code
2. System Owner:
rab
ame
Address(if different from location)
MA
City/Town State C` Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) eptic 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:
Dave Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Loc here contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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