HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 197 INGALLS STREET 10/24/2023 Commonwealth of Massachusetts
City/Town of �tioti�
System Pumping Record
w Form 4
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. —' QrightHOUSE: front back side rear leA. Facility Information BUILDING: nt back side rear le
DECK: under
Important:When
filling out forms 1. System Location;`
on the computer, ll �`
use only the lab S
key to move your Address
cursor-do not P ,- b MA _
use the return Cily/Town Stale Zip Code
key.
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2. System Owner:
N me
Address(if different from location)
_ MA
City/Town Slate .Zip Code
_._ r.2.G—F-(6 - 1 5Z
Telephone Number
B. Pumping Record
1. Date of Pumping ��F��O ----- 2. Quantity Pumped:
le Gall
Da
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. Observed con ition of component pumped:
6. System Pumped By:
Dave Tined _ Mas F582 Mass 1AA95E
Name Vehicl ice umber
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed.
G L S D
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Dale
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