HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 325 SUMMER STREET 10/2/2023 t
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N Commonwealth of Massachusetts
City/Town of
R System Pumping Record
Form 4
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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 I
accordance with 310 CMR 15.351.
HOUSE: fro back side rear eft right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab ` S �
key to move your Address
cursor-do not �� MA C' t�y�
e the return Cityfrown State Zip Code
ke I
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2 System wner.
Name
renm
Address (if different from location) B
MA
CityfTown State Zip Code
U k 4 -K- ((4( _
Telephone Number
B. Pumping Record
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1. Date of Pumping 2
Date _— . Quantity Pumped.
Gallons
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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 G
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass F5821 Ma �195E
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
x
GLS _
Signature of Hauler Date
Signature of Receiving Facility( facility or attach facili receipt) Date
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