HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 30 SUMMER STREET 11/27/2023 �L\ Commonwealth of Massachusetts
City/Town of
N
System Pumping Record �?
Form 4
t14�
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.
A. Facility Infor ation
Left Right front of house, Left/Right rear of house, Left/Right side of house, Under C
Important:when Right side of building, eft/Right front of building, /Right ,ht rear of building,
filling out forms 1. System Location: a /Ri b
g g� L g g g g
on the computer, C
use only the tab � ..�u
key to move your Addres
cursor-do not N .N'-)&U — MA
use the return CityrTown State Zip Code
key.
2. System Owner:
Name
iemm
Address(if different from location)
MA
City/Town State Zip Code
ctl' r* 2q3- ?a1�
Telephone Number
B. Pumping Record
1. Date of Pumping Date Z 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 Mas F5821 IMA A4 9/9�
Name Vehicl umber
Bateson Enterprises, Inc.
Company
7. %tionhere contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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