HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 411 SUMMER STREET 9/19/2022 Commonwealth of Massachusetts RECE��E�
H City/Town of SEP 192p22
a System Pumping Record ANpOVER
Form 4 TOWN OP NOEPARTMENj
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 sid rear ft
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location.
on the computer, / - /YM��
use only the tab 1�1. -I
key to move your Addr ss
cursor-do not A r 17 '/4���vt—
use the return key. City/Town State Zip Code
2. S/ tem Owner:
Name
erma Address(if different from location)
City/Town State / n �363 Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2 Quantity Pumped: 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. Location where contents were disposed:
GLSD -
iz� -- -- - C-� 1:3
Signature of Haul r Date
Signature of Receiving Facility(or attach facility receipt) Date
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