HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 350 BERRY STREET 11/4/2022 i.
Commonwealth of Massachusetts �E�E,vEc
City/Town of _
} System Pumping Record N�� p 42022
Form 4 tvDOVE�
DEP has provided TpWN OpN
information must be substantially the same as that provided here. Befo pEpARTMENS
p o ded this form for use by local Boards of Health. Other is may be used, but the
re 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: Co back side rear e right
A. Facility Inform BUILDING: fron back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
Cursor- not
use the return
urn /'"►'roof �2.
key. City/Town -
State 77- Zip Code
2. System Owner:
Name
man
Address(if different from location)
City/Town
State Zip Code
q0 sra�-
Tel hone Number
B. Pumping Record
1. Date of Pumping
Date 2. Quantity Pumped: 1 J U
Gallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
9 ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes erNo If yes, was it cleaned?
❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Name Mass 1AA95E
Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
LS
4:iggg�na:t uIr e A�c�fH aul e�r
Date --
Signature of Receiving Facility(or attach facility receipt) Date ----- ----_
t5form4.doc• 11/12
System Pumping Record •Page 1 of 1