HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 34 LIBERTY STREET 10/24/2023 Commonwealth of Massachusetts
i City/Town of
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System Pumping Record
w 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 ight
A. Facility Information BUILDING: ront back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, !� Cf ` `
use only the lab v� {- .,SJ�
key to move your Address
cursor-do not N- �ave - MA
use the return Cityrrown State Zip Code
key.
r�
2. System Owner:
Name
Address(if different from location)
_ MA
Cityrrown State . Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping pa�U'-/- 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 conditio of component pumped:
6. System Pumped By:
Dave Tiney _ Mas F5821 Mass 1AA95E
Name Vehicle Aense mber
Bateson Enterprises, Inc. _
Company
7. V
contents were disposed:
G _
16)
Signature of qauler Date
Signature of Receiving Facility(or attach facility receipt) Dale
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