HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 950 JOHNSON STREET 11/28/2022 IC
Commonwealth of Massachusetts
City/Town of
a
System Pumping Record to 2g 202�
Form 4
SH vEf+
OWN ur NpEPAR M NT
DEP has provided this form for use by local Boards of Health. Other AMAL s 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,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, q-50
use only the tab {'LPL30) _ 7S'
key to move your Addres
cursor-do not &
use the return ' -
City/Town State Zip Code
key.
2. System Owner:
gab
Name
iemm
Address(if different from location)
City/Town State ( Zip Code
Telephone Number
B. Pumping Record
At
1. Date of Pumping Date 17 — 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) 'Septic Tank ❑ Tank Tight
g ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ 0 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. LgGzi.Lion where contents were disposed:
Signature of Hauler
Date
Signature of Receiving Facility(or attach facility receipt) Date
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