HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 499 WINTER STREET 4/3/2023 Commonwealth of Massachusetts �ECE►vED
City/Town of _
System Pumping Record
Form 4 ht,�s�L'Er
TCW'�N�OTH DEPA jMENN
DEP has provided this form for use by local Boards of Health. Other forVA Way 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: fron bac side rear le. ri h
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
he tab / 9� / r 1 4 r r
use only the tab "/ (,�
key to move your Addr ss
cursor-do not A,1 dpt,
use the return City/Town �
key. State Zip Code
2. System Owner:
ieb
Name
rcrum
Address(if different from location)
City/Town State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping D2ate 3
2. Quantity Pumped: f�Z�
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 ❑ No
5. Observed condition of omponent pumped:
Y'tVk k
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7.?Signature
n where contents were disposed:
ler
Signature of Receiving Facility(or attach facility receipt) Date
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System Pumping Record•Page 1 of 1
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