HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 707 JOHNSON STREET 10/18/2022 4
a
� Commonwealth of Massachusetts RECEIVED
u City/Town of g 2022
System Pumping Record OCT
Form 4
TOHEALTJOEPARTMNTEi
t I
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 ear left right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Lo a 'o
on the computer, �s
use only the tab
key to move your A dress
cursor-do not
use the return City/Town
key. State Zip Code
2. System Owner:
lift 'j Name
serum
Address(if different from location)
City/Town State
Telephone Nuilhber l�
B. Pumping Record
r
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Ye 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. Local ere contents were disposed:
SD
Signature of er Date
Signature of Receiving Facility(or attach facility receipt) Date
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