HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1041 JOHNSON STREET 7/6/2022 RECEIVED
IL Commonwealth of Massachusetts
City/Town of JUL 0 6 2022
a ° System Pumping Record
OF NORTH
Form 4 TOWN
HEALTH DEPARTMENTER
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. -- --
HOUSE: front back sid r r left right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. S tern Location:
on the computer,
use only the tab y
key to move your Address
cursor-do not
use the return key. City/Town State Zip Code
2. System Owner:
rab V _
Name
iemm
Address(if different from location)
City/Town Stat p Code
S
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2 Quantity Pumped: Gatons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
-- - - n 6w 7
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
GLSD
r
Signature r Date
Signature of Receiving Facility(or attach facility receipt) Date
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