HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 826 JOHNSON STREET 5/31/2022 Commonwealth of Massachusetts
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a - System Pumping Record acNPN°Nc
Form 4 �OH�O�No-pP��ME
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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 CM 15.351. --- --
HOUSE: front back ide rear eft right
A. Facility Information BUILDING: front back sl a rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab l l�
key to move your AddYess
cursor-do not
use the return
key. itylTown State Zip Code
2. Sy tem Owner:
gab
me
rerwd
Address(if different from location)
City/Town State � 3 Zip Code
99
Telep one Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: ,SGb
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: /
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loc where contents were disposed:
LS
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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