HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 624 BOXFORD STREET 11/21/2023 'C\ Commonwealth of Massachusetts
HROM City/Town of y
System Pumping Record4
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 reara right
A. Facility Information BUILDING: front back side rear left right
Important:When
DECK: under
filling out forms 1. System Location:
on the computer, r'+ l�j
use only the tab l�
S47
key to move your Address
cursor-do not ��LX� MA
use the return Ci /Town 6 7
key, y State Zip Code
VQ 2. System Owner:
Name
rerun
Address(if different from location)
MA
City/Town State, _ c Zip Code
Telephone Number
B. Pumping Record P
1. Date of Pumping cv`3c� '_
P� 9 �� 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): --
4. Effluent Tee Filter present? ❑ Yes 4 No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed conditio of component pumped:
6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA95E
ame Vehicle icens umber
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed.
LLSD)
Signature of Hauler Date -- — _ —-
Signature of Receiving Facility(or attach facility receipt) Date --
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