HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 338 BERRY STREET 11/21/2023 :�L\_ Commonwealth of Massachusetts
N City/Town of
System Pumping Record Np1
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 Information
{ Left/Right front of house, Left/Right rear-of house, Left/ ight side of house, Under[
Important:When
filling out forms 1. S st m Location: Left/Right side of building, Left/Right front of building, a Right rear of building,
on the computer, ((
use only the tab 'S��
r~
key to move your Ad r s
cursor-do not MA
use the return ity/Town State Zip Code
key.
2. System Owner:
Name
ixun .
Address(if different from location)
MA
City/Town State Z ip_Code
Telephone Number
B. Pumping Record
Date of Pumping Date 2 Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yeol No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass F1,r,5)Aa5
Name Vehicle Lice
Bateson Enterprises, Inc.
Company
7. LoF' re contents were disposed:
1157
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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