HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 1429 OSGOOD STREET 8/18/2022 (3) Commonwealth of Massachusetts RECEIVED
City/Town of AUG 18 2022
System Pumping Record
Form 4 TOWN OF NpEFAR MENTER
HEALTH
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 side rear left right
A. Facility Information BUILDING: iron back side rear left rig t
Important:When DECK: under
filling out forms 1. System Location:
on the computer, l ,� I
use only the tab 7 oC 1 --_ l^�.f<,0001 "5_r ✓ v ' And r1Una,
key to move your Address
cursor-do not
use the return key. City/Town State Zip Code
2. System Owner:
rob
Name
ierwn
Address (if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping $—t 0- oZoZ 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) ES(//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 com onent pumped.
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. LocatijQn where contents were disposed:
GL
i
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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