HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 JOHNNY CAKE STREET 11/4/2022 i. �EGEIVEI-'
Commonwealth of Massachusetts
r City/Town of NOv 42022
System Pumping Record o�NORH M�°;T
Form 4 TOHEAE'TV,ospos
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 bac side rear left right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, 6
use only the tab
key to move your Add ess � ✓
cursor-do not
use the return
key. City/Town
State Zip Code
as
2. Syst m Owner:
6
Name
ieroin
Address(if different from location)
City/Town State
Zip Code
Telephone Number
B. Pumping Record
Date of Pumping
Date � 2. QuantityPumped:
p Gallons _—
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
9 ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned?
Yes ❑ No
5. Observed conditi n 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:
LS
Signal of Hauler
Date
Signature of Receiving Facility(or attach facility receipt) Date
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System Pumping Record•Page 1 of 1
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