HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 FARNUM STREET 8/23/2023 � Commonwealth of Massachusetts
City/Town of PR;��`"r�A pti3
System Pumping Record No�� OGti`�ti
Form 4 N
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 �acsidti� rea left right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, r
use only the tab 1[ S
key to move your Address
cursor-do not _ MA _ ��)
use the return key. City/Town State Zip Code
2. System Owner:
1(� (C___ _
Name
rerun
Address(if different from location)
MA _
City/ own State -- Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping � �-2� - --- 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. Obse}rv9e�d�cond'tion of component pu ped:
6. System Pumped By:
Dave Tine_y _ _ Ma&-br
Mass 1AA95E
Name Veh
Bateson Enterprises, Inc.
----
7. ion where contents were disposed:
GLSD
- -- - - -- tio
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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