HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 328 SUMMER STREET 10/2/2023 �i Commonwealth of Massachusetts
City/Town of
a
System Pumping Record `� ' ' ptiti�ti3
Form 4 OCR
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: ont ack side rear (9 right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not �3 n, IN���,.q� _ MA (3 1 VS jG
use the return Cityrrown State Zip Code
key.
2. System Owner:
M� / SLhl:ylrC�
Name -
Address(if different from location)
MA
Cityrrown State Zip Code
Telephone Number
B. Pumping Record 91 1. Date of Pumping Date I ^ 1_ 2. Quantity Pumped: Gallons �)6
3. Component: ❑ Cesspool(s) [� Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes K No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
UioCMA�
6. System Pumped By:
Dave Tiney Mass F5821 Mass AA9
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. L ation where contents were disposed:
GLS
a:
`�( I Oo
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc- 11/12 System Pumping Record•Page 1 of 1
I