HomeMy WebLinkAbout- Septic Pumping Slip - 700 MIDDLETON STREET 7/3/2023 �L\ Commonwealth of Massachusetts
City/Town of
System Pumping Record JUL p 3 2023
Form 4
�M
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 System 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.
A. Facility Info ion_ _ (�:f
ee ight front of house, t/ Rig t rear of house, Left/Right side of house, Under Dec
Important:Whenfilling out forms 1. S stem Location. Left/ Right side of building g t front of building, Left/Right rear of building,
on the computer, �j 0
use only the tab CJCJ ���--- —
key to move your Address
cursor-do not i4 "v" tJ'"Q L MA ` ✓I
use the return Cit /Town State Zip Code
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2. Syst m Owner:
P1�r''t�Yy� -- --- -
Name
Address(if different from location)
MA
City/Town State Code
-ASS _Zip�a�
Telephone Number
B. Pumping Record
L_�
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?1--t Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tine Mass F5821_ IN M 95�
Name Vehicle License umber
Bates_on Enterprises, Inc.
Company
7. Location where contents were disposed:
G LS D---- --- — - --
-c;2_3�
Signature u er Date
Signature of Receiving Facility(or attach facility receipt) Date
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