HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 337 SUMMER STREET 11/27/2023 Commonwealth of Massachusetts
City/Town of
�0
a _ System Pumping Record
Form 4
M
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: fron back sid�re left right
A. Facility Information BUILDING: t back side left right
Important:When
DECK: under
filling out forms 1. System Location:
on the computer, S
use only the tab S5�_ SuO^Maf
key to move your Address
cursor-do not MA
use the return Cit frown
key. y State Zip Code
Q2. System Owner:
4{ �255 / �1cti r A S -- -
Name - - - - - -
rarun
Address(if different from location) .
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date/ Z 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 condition of component pu ped:
tO brr-%k\
6. System Pumped By:
Dave Tiney Mas F5821 Mass 1AA95E
Name Vehicl icens umber
Bateson Enterprises, Inc.
Company
7. ation where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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