HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 265 SUMMER STREET 10/24/2023 Commonwealth of Massachusetts PG-0,N,
City/Town of _ �P�-�N �p
System Pumping Record
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.
HOUSE: front back side rear left ight
A. Facility Information BUILDING: ront back side rear left right
DECK: under
Important:When
filling out forms 1. System Location.
on the computer, �^� CC �t
use only the tab �, �uMMe r T
key to move your Address
cursor•do not 0 MA Gk all.—IC.-_
use the return ityrrown Stale Zip Code
key.
2. System Owner: 1
Name
nnm
Address (if different from location)
__ MA ____ _
City/Town State Zi Code
201-3�-�-F5� g�*
Telephone Number
B. Pumping Record
101 ('dt3
1. Date of Pumping Dale 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. Observed c ndition of component pumped:
�6CMa�
6. System Pumped By:
Dave Tiney _ Ma V65821 Mass 1AA95E
Name Vehi e Licens umber
Bateson Enterprises, Inc. _
Company
7. where contents were disposed:
CeAtion
SD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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