HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 59 JOHNNY CAKE STREET 11/28/2022 Commonwealth of Massachusetts RECEIVED
u City/Town of
a
System Pumping Record Nov 29 ZW
M Form 4 `OWN OF rj0F fH ANDOVEF
HEALTH DF_PAFITMENT
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: Vnt
back side rea le right
A. Facility Information BUILDING: back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, S l 1 J� I
use only the tab _ (•iYt✓I�-i _ _ _ _ _
key to move your Address
cursor-do not
use the return - -- - - - -
key.
City own State Zip Code
2. System Owner:
Nam - ---- - --
rernrn
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: GallonsU
3. Component: ❑ Cesspool(s) ptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): - - --
4. Effluent Tee Filter present? ❑ YesAf 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
mp Coany - -
7. Location where contents were disposed:
LS
Signature ofr
er Date
Signature Receiving Facility(or attach facility receipt) Date
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