HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 125 JOHNNY CAKE STREET 7/3/2023 7
<�N_ Commonwealth of Massachusetts
City/Town of
System Pumping Record
{ 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 yoi
local Board of Health to determine the form they use. The System Pumping.Record must be submitted
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 back ide ear left righ
A. Facility Information BUILDING: front back side rear left righ
DECK: under
Important;When
filling out forms 1. System Location:
on the computer, 15 \ , /
use only the tab 1 1 `J� 0'�- Y\
key to move your A dress^ A
cursor-do not ,1 \�djplr �/(C, Oft
use the return City/Town State Zip Code �1
key.
2. System
�9 caner: r
l�
Name
mwn --
Address (if different from location)
City/Town . State ip code
Telephone Number 1
B. Pumping Record
1. Date of Pumping ��fDate /� 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? ❑ Yes ❑ No
5. Observed condition of component pumped:
Wo C,f% .k
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. EGILSD
lion where contents were disposed:
b� Ik Z3
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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