HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 119 LIBERTY STREET 11/27/2023 Commonwealth of Massachusetts
City/Town of
a
System Pumping Record
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 le righ
A. Facility Information BUILDING: front back side rear left rig
i Important:When
DECK: under
filling out forms 1. System Locatio
on the computer, c, c `
use only the tab 11 � Y>
key to move your Address
cursor-do not
use the return City/Townl ` UV MA
key. State Zip Code
VQ 2. System Owner:
Name
�enm
Address(if different from location) . --
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Z 4
P 9 �I �� � 2. Quantity Pumped: -
Date y p 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 condifon of component pumped:
6. System Pumped By:
Dave Tiney Mas F5821 Mass 1AA95E
Name Vehicl License umber
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
GLSD II
//A. 6
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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