HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 350 BERRY STREET 11/21/2023 'CN Commonwealth of Massachusetts
u City/Town of 01.E
System Pumping Record �pV
M
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 ack side re left right
A. Facility Information BUILDING: back side 'rear right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab 2P�'
key to move your Address
cursor- not (Qy�
use the return
urn _ MA 6-
key. CityrTown State
Zip Code
rab 2. System Owner:
t n�1g NG SS�—
Name
�etun
Address(if different from location)
MA
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date I IZ� 2 Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): -------_-_
4. Effluent Tee Filter present? ❑ YestNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed con ition of component ped:
L
6. System Pumped By:
Dave Tiney Mas F5821 Mass 1AA95E
Name vehicl Licen umber
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
GLS %/�6
Signature of Hauler Date b-3
Signature of Receiving Facility(or attach facility receipt) Date
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