HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 481 REA STREET 10/24/2023 Commonwealth of Massachusetts
City/Town
Pumping Record
System p g pp�
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 bac ide rear le le
A. Facility Information BUILDING: front back side rear left
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, Lf&
use only the lab �l
key to move your A dress
cursor-do not (l�� MA
use the return C1lty/7own —'— Stale Zip Code
key.
2. System Owner::
A
Name
norm ------------
Address (if different from location)
MA _
City/Town StatQ _ ,�����Z1P Code
Telephone Number `4f
B. Pumping Record ,
�D I -I ___— 2 QuantityPumped:
fs
1. Date of Pumping Date p 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 condI t I of component pumped.
6. System Pumped By:
Dave Tiney Mas F5821 Mass 1AA95E
Name vehicl Licen umber
Bateson Enterprises, Inc.
Company
7. Mtiicn where contents were disposed
GLS —_. --- --
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Dale
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