HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 991 JOHNSON STREET 9/19/2022 V_ECENE%
Commonwealth of Massachusetts
= City/Town of sy 1 9N22
System Pumping Record oF�,oRrHA�oov "`
Form 4 TOWN DEPART�EHT
HEATH
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 ea a right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location: h
on the computer, �Gi 1 1 �� s� 5` VA'
use only the tab l t
key to move your Address
cursor-do not _
use the return State Zip Code
City/Town
key.
2. System Owner:
OL
Name
Address (if different from location)
City/Town State Z' Code
Telephone Number
B. Pumping Record
2. Quantity Pumped: Gallonst
1. Date of Pumping Date
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? es ❑ No
5. Observed co dition of component pumped:
�9�✓11a. � �c -
1
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
GL
s
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11112 System Pumping Record•Page 1 of 1