HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 371 STEVENS STREET 9/19/2022 Commonwealth of Massachusetts REGE,vEa
City/Town of
a System Pumping Record SEp 192022
NpovEa
Form 4
WN OF NORTHP MENT
TO ( orrms may be used, but the
DEP has provided this form for use by local Boards of Healtl�lEw Before using this form, check with your
information must be substantially the same as that provided here. g
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 ear e right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location: � � ' ���
on the computer, ! �.,..�J.� S t/`�
use only the tab
key to move your Address
cursor-do not
use the return CitylTown State Zip Code
key.
2. System Owner:
Name
niwn
Address(if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
_ -;�Se�ptic
Quantity Pumped: Gallons oo1. Date of Pumping Date3. Component: ❑ Cesspool(s) Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe).
4. Effluent Tee Filter present?T—esVNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tine Mass 1AA95E
Vehicle License Number
Name
Bateson Enterprises Inc
Company
7. Locat here contents were disposed:
LGLS — - H
Signature of Hauler
Date
Signature of Receiving Facility(or attach facility receipt) Date
System Pumping Record• Pag,e 1 of 1
15form4.doc• 11/12