HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 502 WINTER STREET 10/2/2023 t
Commonwealth of Massachusetts t
= City/Town of
a ° System Pumping Record
Form 4
i
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: ron back side rear eft right
A. Facility Information BUILDING: front back side rear left right e
Important:When DECK: under
filling out forms 1. System Location.
on the computer,
use only the tab co,
key to move your Address
cursor not return
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use the return City/Town Stale Zip Code
key.
2. System Owner:
)�oc
Name
niun
Address(if different from location)
t
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
CQ� TAP
1. Date of Pumping Date lf� 2. Quantity Pumped: Gallons E
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): - --
u
s
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6(-M,
b
6. System Pumped By:
Dave Tiney Mass F5821 M ss 1AA95E
Name Vehicle License Number i1
6
Bateson Enterprises, Inc. t
Company
7. ation where contents were disposed:
GLSD _
I
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
I �
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