HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 557 BOXFORD STREET 10/24/2023 Commonwealth of Massachusetts
City/Town of
System Pumping Record
w,
Form 4 OL
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 ack side rear left righ
A. Facility Information BUILDING: ront back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the lab �— --—.
key to move your Add ss
cursor-do not
MA
use the return
ly/Town State Zip Code
key.
2. System Owner:
Name y
Address (if different from location)
MA
city/Town State n Zip�Code
�, --
Telephone NumbersB. Pumping Record /
1. Date of Pumping — - --- 2. Quantity Pumped:
Date r Gallons
3. Component: ❑ Cesspool(s) �] Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): —r----
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed cco�n�ditti n of component pumped:
6. System Pumped By:
Dave Tiney _ Mas 582 Mass 1AA95E
Name Vehicl icens tuber
Bateson Enterprises, Inc.
Company
7. where contents were disposed:
L D
0 Signature of auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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