HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 850 JOHNSON STREET 9/19/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of SEP 192022
o System Pumping Record Nog'*V, O,T
iON1N OF EpARTME
Form 4 HEAjTHD
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 eft ight
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
1. System Loca on:
filling out forms y
on the computer,
use only the tab v
key to move your Address
cursor-do not &9691V- (Code
City/Town l
use the return State Tip
key.
2. System Owner:
ab IL�r%if`A
C
Name
ierwn
Address(if different from location)
City/Town State ZipCode
6,0 �— � c
Telephone Number B. Pumping Record2 // � �G�✓ ._---
1. Date of Pumping 2. Quantity Pumped: Gallons
Date
3. Component: ❑ Cesspool(s) eptic 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. ation ere contents were disposed:
GLS _
Signature of Haule Date
Signature of Receiving Facility(or attach facility receipt) Date
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