HomeMy WebLinkAboutTight tank - Septic Pumping Slip - 1429 OSGOOD STREET 4/3/2023 Commonwealth of Massachusetts
RECE1V�U
City/Town of
System Pumping Record
Form 4 �oN o: OVPR�M�N
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 Syste.m 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: ron back side rear left i ht
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location: n
on the computer, �,/
use only the tab (0f t�CJ CCC///ttl
key to move your Ahlress
cursor-do not
use the return
AA
key. ity/Town St to Zip Code
2. System Owner:
Name
mwn '
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record 3 2
a i�6
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank Tight Tank ❑ Grease Trap
❑ Other (describe): -- -- -- -- --
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ Nc
5. Observed condition of component pumpe
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents w re disposed:
GLSD
Signature of Ha Date
Signature of Receiving Facility(or attach facility receipt) Date
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