HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1538 TURNPIKE STREET 4/3/2023 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4 ;'.
cc N OF MOR-(M�N E��
DEP has provided this form for use by local Boards of Health. �T��Q1<Ih��l���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. — --- ...- ..
HOUS front b ck side rear e. right
A. Facility Information BUILDING: ront back side rear eft right
Important:When DECK: under
filling out forms 1. System Locat
on the computer, /53(�¢ ew
use only the lab
key to move your Addr ss
cursor-do not
use the return
key. Uty/Town State Zip Code
deb 2. Sy tem Owner:
t
Name
nnan r
Address(if different from location)
City/Town . Stat Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
p 9 Date 2• Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) 4Septic 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 component pu ped:
6. System Pumped By:
Dave Tin Mass 1AA95E
Name
Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where ntents were disposed:
GLSD
Signature f auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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