HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 784 WINTER STREET 11/21/2023 Commonwealth of Massachusetts
City/Town of
~ System Pumping Record �1ti013
Form 4 1p�
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�ro�nthack
�kse rear le righ
A. FaClllty InfOrmatlOn BUILDINe rear left right
Important:When DECK: under
filling out forms 1. System Location.
on the computer, f 1 n
use only the tab �
key to move your Address
cursor-do not L� N\
use the return MA
key. Cityfrown State Zip Code
2. System Owner: I
le-"a /ton
Name
ream
Address(if different from location)
MA
Citylrown State
Ct �' �Itl p Code
Telephone Number
B. Pumping Record
'1 18-"1. Date of Pumping Date 2. Quantity Pumped: God
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 ❑ Nc
5. Observed condition of component pu ped:
bCIM
6. System Pumped By:
Dave Tiney 582- - Mass Mass 1AA95E
Name Vehicle Number
Bateson Enterprises, Inc.
Company - - - -
7. tion where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1