HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 169 GRAY STREET 10/2/2023 -C\- Commonwealth of Massachusetts
City/Town of
a System Pumping Record
Form 4 �L
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 Information
Left/Right front of house, Left/Right rear--of house, Left Right:side f house, Under I
Important:When
filling out forms 1. System Loca on: Left/Right side of building, Left/Right front of building, Left/Right rear of building,
'
on the computer,
use only the tab (/��{ //Q�/
key to move your d res MA v G V—r _
cursor do not M icWoel
use the return City/Town State Zip Code
key.
2. Syslem Owner:
rah *—h)
Name
BI Address(if different from location)
MA
CitylTown State 3 �9_ (�(/ ode
-_
Telephone Number (,/Y
B. Pumping Record
f Pum in -- 2. Quantity Pumped:
1. Date o p 9 Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe). --
4. Effluent Tee Filter present? Ves ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 175821 yQ 1A4551Q>
Name Vehicle License umber
Bateson Enterprises, Inc.
Company
7. Lo where contents were disposed.
GLSD
- — /
Signatur ler Date
Signature of Receiving Facility(or attach facility receipt) Date
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