HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 285 REA STREET 7/3/2023 1'—*\ Commonwealth of Massachusetts
City/Town of
F System Pumping Record `o32oti3
{ Form 4 w
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. - -
HOUSE front ack side re le right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. S tern Location:
on the computer,
use only the tab
key to move your Ad press
cursor-do not k40_) 0l(
use the return ity/Town Slate Zip Code
key.
2. Sy tem Owner:
N me
nran '
Address (if different from location)
City/Town . State, Ip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 3 2. Quantity Pumped: !�
Date Gallons
3. Component: ❑ Cesspool(s) eptic 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:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents e disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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