HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 557 BOXFORD STREET 10/18/2022 �ECEIVEu
Commonwealth of Massachusetts pCT 1g2nz
City/Town of
System Pumping Record ��'"lq°FHORNVA PA�M�TER
y p J N�
Form 4
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: ack side rear left I ht
BUILDING: front back side rear left right
A. Facility Information
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, �t)
use only the tab l•��
key to move your Adc1ceas
cursor-do not U69 ` -f- V17/l i
use the return City/Town State Zip Code
key.
2. System Owner:
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Name
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Address(if different from location)
City/Town Stat��� Z}p Code
Telephone Number
B. Pumping Record
D to of Pum in 10_4?,�2_ 2. Quantity Pumped:
1. a p 9 Date G I ons
3. Component: ❑ Cesspool(s) 4Septic 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. Location where contents were disposed:
GLSD
_ a
Signature o auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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