HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 JOHNNY CAKE STREET 12/4/2023 Commonwealth of Massachusetts
City/Town of P4� '
System Pumping Record It
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 bac sid rea left right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location.-
on the computer, � ^ 1,
use only the tab � Yl(��/ S C s
key to move your Ad r ss `
cursor-do not '
use the return MA
key. City/Town - State
Zip Code
2. System Owner:
\Z�a A
rd
Name-
Address (if different from location) .
MA
Cityrrown
State � � J('��Zip Code
G3&- -�V 3a
Telephone Number
B. Pumping Record
Date of Pumping Z�`Z,� 2. Quantity Pumped: /5od
Date y p Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Ye No If yes, was it cleaned? Yes ❑ No
5. Obsi;g
ition of cc onent p mped:
6. System Pumped By:
Dave Tiney Mass F58214umr
ass 1AA95
Name Vehicle License
Bateson Enterprises Inc.
Company
7.aoc where contents were disposed:
1
Signatur Hauler
! 2
2
Date
Signature of Receiving Facility(or attach facility receipt) Date
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