HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 371 SUMMER STREET 10/24/2023 Commonwealth of Massachusetts
City/Town of v;� 19C,
a System Pumping Record J�L� �
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 re le right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
(n the
out forms 1. System Location:
on the computer, e1 S�tM fte sy
use only the tab 1
key to move your Add �
cursor-do not MA _
use the return City/Town Stale Zip Code
key.
2. System Owner:
n Name
Address (if different from location)
_ MA _ __ _
City/Town State .Zip Code
9 Z3 253Z
Telephone Number
B. Pumping Record
1. Date of Pumping oae - ----- 2. Quantity Pumped: Gallon
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 pumped:
6. System Pumped By.
Dave Tiney _ Ma F5821 Mass 1AA95E
Name Vehi Licens umber
Bateson Enterprises, Inc.
Company
7. oca n where contents were disposed:
GLSD —_
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Dale
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