HomeMy WebLinkAboutFailed pump - replaced - Septic Pumping Slip - 180 BERRY STREET 11/27/2023 Commonwealth of Massachusetts
tity/Town of
System Pumping Record 2p23 a y ��
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.
A. Facility Info ion
Left ight front of house, Left/Right rear of house, Left/Right side of house, Under E
Important:When a Ri Right side of buildin Left/ Right front of building, Left/Right rear of building,
filling out forms 1. Sy t m Loca ion: / g
on the computer,
use only the tab
key to move your Iddress
cursor-do not MA
use the return ity/Town State Zip Code
key.
2. SVStenn Owner:
WA M
ame
Address(if different from location)
MA
City/Town StatV/3 _ C
Code
Telephone Number
B. Pumping Record AM
1. Date of Pumping Date 2, Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ElGrease Trap
Other (describe). "_d
4. Effluent Tee Filter present. ❑ Ye If yes, was it cleaned? ❑ Yes ❑ No
,5L
5. Observed condi ion of component pumped:
6. System Pumped By:
Dave Tiney _ Mass F5821 _ A A15-je
Name Vehicle Lice umber
Bateson Enterprises, Inc.
Company
7. Los' re contents were disposed:
LSJD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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