HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 10 PURITAN AVENUE 5/2/2023 Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record
Form 4
p�1WN OF NUR`rt�ANDUT
DEP has provided this form for use by local Boards of Health TCJh ��f� R{ jTueEused, but the
I 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 tc
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 Ek side rear right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System ocati In
on the computer•
use only the lab u< %
key to move your Address
cursor•do not ` 1Lr /�/��
use the return
key. City/Town State• Zip Code
2. System Owner:
C
Name
ttiwn
Address (if different from location)
City/'Town . State Zip Code
Telephone Number
B. Pumping Record ,
1. Date of Pumping Dale 2. Quantity Pumped: �a w
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 component pumped:
l�Uarliy►a,
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L.Mqtion where contents were disposed:
Signature of Hauler Date
t
Signature of Receiving Facility(or allach facility receipt) Date
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