HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 970 JOHNSON STREET 12/5/2022 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record
Form 4 foWN t-tEA F NoFt-VH E6
HEAL DEPAR MENT
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 back side rea right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Locatlop.
on the computer, / �
use only the tab \ J
key to move your Adgiress
cursor-do not ,'��J/, /
use the return :,• '"' y — / �V & (/(
`
key. City/Town State Zip Code
2. > Owner:
iab `\/6
Name
reran '
Address(if different from location)
City/Town State Zip Code
Tele one Number
B. Pumping Record
1. Date of Pumping Date A �2. Quantity Pumped:
Gallons
3. Component: ElCesspool(s) Vseptic Tank ElTight Tank ElGrease Trap
Other (describe):
4, Effluent Tee Filter present? ❑ Yes C o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pu ped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
GLSD
Signature of Hauler Date
i
j Signature of Receiving Facility(or attach facility receipt) Date
I
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System Pumping Record•Page 1 of 1
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