HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 547 WINTER STREET 8/23/2023 Commonwealth of Massachusetts
City/Town of
a
System Pumping Record �tioti3
Form 4 P�Vti
�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: nt ack side rea left right
A. Facility Information BUILDING(:�nt back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, f `
use only the tab 51 �: - _ _
key to move your Addr ss
cursor-do not MA _
use the return City/Town State Zip Code
key.
2. System Owner:
rah
-e-v --
Name
Address(if different from location)
_ MA
City/rown State Zip Code
�S 1 - o c(y-7_ zz
Telephone Number
B. Pumping Record l
1. Date of Pumping 2. Quantity Pumped: ��
Date 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 ofcomponent pumped.
1 - --- --- - -- - --
6. System Pumped By:
Dave Tiney MasaF582 _Mass 1AA95E
Name Vehicber
Bateson Enterprises, Inc.
Company
7. ion where contents were disposed:
CGLSD
Signature of H uler Date
Signature of Receiving Facility(or attach facility receipt) Date
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