HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 37 SULLIVAN STREET 10/24/2023 Commonwealth of Massachusetts
NLF�`C
= City/Town of
b System Pumping Record L� `L�ti4
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: iron bac side rear le®rl
A. Facility Information BUILDING: front side rear le
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab S�t I 'LU�in �✓
key to move your Ad-dress
cursor-do not /j- &0, _ MA _ LIN
use the return Cily/Town Stale Zip ode
key.
2. System Owner:
Name
Address (if different Irom location)
MA _
City/Town --- -- — State 12>031 -- — p Code
Telephone r i-/Z-
B. Pumping Record
1. Date of Pumping pale[ Z — ---- 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 condition of component pu ped:
6. System Pumped By:
Dave Tines _ M a s F582 Mass 1AA95E
Name vehicl License Number
Bateson Enterprises, Inc.
Company
7.Cocon where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility(—or attach facility receipt) Date
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