HomeMy WebLinkAbout- Septic Pumping Slip - 465 CHESTNUT STREET 8/7/2023 P"\ Commonwealth of Massachusetts paR��a1�N�
u City/Town of N�P��NO� G 0,� tipti3
System Pumping Record a�
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. --- -
HOUSE: front ac side rear le right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, t�!
use only the tab
key to move your Address _
cursor-do not
use the return
key.
City/Town State Zip Code
2. System Owner:
rab n
e— ` 3 u --- - — -- -- —
Name
renm
Address (if different from location)
MA
City/Town State Zip Code
-�-y2` - —
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: llof-
p g Date Gans
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:
6. System Pumped By:
Dave Tiney M s F5821 Mass 1AA95E
Name Vehi a License umber
Bateson Enterprises_, Inc.
Company
7. tion where contents were disposed:
GLS
Signature'of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1