HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 337 SUMMER STREET 11/28/2022 Commonwealth of Massachusetts RECEtvED
City/Town of
a 2
System Pumping Record NOV
' No�TH ANoovEI�+
Form 4 SOHEA jHC)EPART T
MEN
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the.sarne 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 C M R 15,351. --
HOUSE: front ack side rear left right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System cation:
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return Ci y/Town State Zip Code
key.
2. System Owner:
ub
SSi rat
Name
rnum
Address(if different from location)
City/Town State Zip Code
o - i, V
Telephone Number B. Pumping Record - -
1 l 1 j a-- r '�S-b c-)
1. Date of Pumping Date — 2• Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) ptic Tank ❑ Tight Tank g El 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:
G SS D
Signature of Hauler Date —
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc, 11/12
System Pumping Record•Page 1 of 1