HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 991 JOHNSON STREET 10/2/2023 Commonwealth of Massachusetts
City/Town of
System Pumping Record � y` ®R►ti���
w
Form 4 0C�
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
S 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 bac side rear left Igh
A. Facility Information BUILDING: front back side rear left rig t
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, C(0S
use only the tab "`'"� J
key to move your Address
cursor-do not MA Q L
use the return key. Ciry7rown State Zip Code
2. System Owner:
Name
�enm
Address (if different from location)
MA
City/Town State Zip Code
g(a OR—
Telephone Number
B. Pumping Record
1. Date of Pumping Date L 2 Quantity Pumped: 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�rv1edd ccondiittioon of component pumped:
Nlo •/�'"1J\
6. System Pumped By:
Dave Tiney ass F5821 Mass 1AA95E
Name Vehicle Licens umber
Bateson Enterprises, Inc.
Company
7. oc 'on where contents were disposed:
GLSD
Signatu f Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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