HomeMy WebLinkAboutTight Tank - Septic Pumping Slip - 1429 OSGOOD STREET 1/6/2023 Commonwealth of Massachusetts
r City/Town of _
REGEIVE� .
a System Pumping Record p62p23
Form 4 BAN vER
OF NO(�Y1'��MENT
SOWN EIP
DEP has provided this form for use by local Boards of Health. Other forp"Vy 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: nt ck side rear le k io
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location.
on the computer,
use only the tab A�
key to move your Addr ss
cursor-do not
use the return Tty/Town
key. State Zip Code
2. System Owner:
I,� a.
Name
rnwn r
Address(if different from location)
City/Town . State
Zip Code
Telephone Number
B. Pumping Record
/ J
1. Date of Pumping 3Date 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) ❑ 'Septic Tank �ght Tank ❑ 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 Tin Mass 1AA95E
Name
Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
GLSD
Signature of Hauler
Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11112
System Pumping Record•Page 1 of 1