HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 2109 TURNPIKE STREET 5/31/2022 Commonwealth of Massachusetts
u City/Town of
System Pumping Record
vE
Form 4 MP D��N A�MENj
F N pR
DEP has provided this form for use by local Boards of Health. Other fo i�i1 used, but the
information must be substantially the same as that provided here. Before�iing 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. —
HOUSE: front back side rear left right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab (� �
key to move your r ss r 0
cursor-do not
use the return ity/Town 'State Zip Code
key.
2. System Owner:
/P4/ ,P
me
ierwn
Address(if different from location)
City/Town State � C ����� Zip Code
Telephone Number
B. Pumping Record
56-
1. Date of Pumping ate 2. Quantity Pumped: Gallon
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
Bates_on Enterprises_Inc
Company
7. Loc here contents were disposed:
7
LSD f//
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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