HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 767 JOHNSON STREET 10/24/2023 Commonwealth of Massachusetts
City/Town of
System Pumping Record OC��
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 side rear left ight
A. Facility Information
BUILDING: front back sierear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, -4r1'f i_ v � c�
use only the tab �pT1J
key to move your Address
cursor-do not _ MA _
use the return � ���V� -- —
City/Town State Zip Code
key.
2. System Owner:
,.e
eC( 4 - -- -
Name
Address (if different from location)
MA
City/Town State Zip Code
_ agg-5 %--sue_ r
Telephone Number
B. Pumping Record
1. Date of Pumping Date — --- 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 pumped:
6. System Pumped By:
Dave Tiney _ _ _ Mass F5821 Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises, Inc. _
Company
7. Laczlion where contents were disposed:
LSD
Signature oC,,le, Date
Signature of Receiving Facility(or attach facility receipt) Date
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