HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 311 DALE STREET 10/24/2023 Commonwealth of Massachusetts
City/Town of
a System Pumping Record pL�
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 rear left right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location.
on the computer,use only the tab 3,t t S t
' V,,12 -t-
key to move your Addres
cursor-do not �t.R� _ _ MA _ ON
use the return key. City/Town Slate Zip Code
2. System Owner:
rd ``
Name
nnm
Address(if different from location)
MA
City/-rown State .Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping IZ�------ 2. Quantity Pumped:
Date 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 con tion of component pumped:
6. System Pumped By:
Dave Tiney _ Ma F582 Mass 1AA95E
Name Vehic Lice Number
Bateson Enterprises, Inc. _
Company
7. L •on where contents were disposed:
LS
l to S
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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