HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 781 WINTER STREET 9/25/2023 Commonwealth of Massachusetts
City/Town of tioti3
a System Pumping Record
a
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 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.
A. Facility Info Ma '
Left Right nt of house, Left/Right rear of house, Left/Right side of house, Under[
Important:When
filling out forms 1. System Location: Left t side of building, Left/Right front of building, Left/Right rear of bus ing,
on the computer, C
use only the tab
key to move your A ress
cursor-do not MA
use the return City/Town State Zip Code
key. y
2. Sy em Owner:
red
Nam
serum .
Address(if different from location)
MA
City/Town State Zip Code
y10
Telephone Number
B. Pumping Record
1 Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): 0 ._- - --
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5 Observed condition of co ponent pu ed:
6. System Pumped By:
Dave Tiney Mass F5821 I&A M 95Q
Name Vehicle License 4 umber
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed.
GLSD
- - - -
Signature of Date
Signature of Receiving Facility(or attach facility receipt) Date
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