HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 28 JERAD PLACE 7/3/2023 Commonwealth of Massachusetts
City/Town of
System Pumping Record �u` p32�23
{ Form 4
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
local Board of Health to determine the form they use. The System Pumping.Record must be submittE
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 ack side rear left ri
A. Facility Information BUILDING: front back side rear left ri
DECK: under
Important:When
filling out forms 1. System Locatio
on the computer, z8- '`4 l
use only the tab G
key to move your Addres
cursor•do not �,.rt
use the return City/Town wv v Slate Zip Code
key.
2. System Over:
Name
Nwn
Address (if different from location)
Cily/Town . State Zip Code
?A R21
Telephone Number
B. Pumping Record 1
1. Date of Pumping C'�15lZ3 _ 2. Quantity Pumped: /S
Dale Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Tra{
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed con Rion of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E � �-
Name Vehicle License Number
Bateson Enterprises Inc
Company
7, on where contents were disposed:
GLSD
Signature o auler Dale
Signature of Receiving Facility(or attach facility receipt) Dale
I5(orm4.doc 11112 System Pumping Record - Page