HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 208 SUMMER STREET 12/21/2023 Commonwealth of Massachusetts
= City/Town of tioti
a System Pumping Record
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 rear e right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab �U�_ (h Q-/ S.
key to move your Address
cursor-do not fv\ \ Q
Y t�
use the return � ^ h MA
key. CitylTown State
Zip Code
2. System Owner:
—- bIA&
Name
nnm
Address(if different from location) .
City/Town — MA
State Zip Code
:3frt - Z"- (-IIF2
Telephone Number
B. Pumping Record
1 Date of Pumping Date21`t'Z� 2. Quantity Pumped:
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 ❑ No
5. Observed condition of component pumped:
Ill)n cnen4
6. System Pumped By:
_Dave Tiney Mass F5821 Mass 1AA95
Name Vehicle License Nu ber
Bateson Enterprises Inc.
Company
7. tion where contents were disposed:
GLSD
Signature o�r 4at
Signature of Receiving Facility(or attach facility receipt) Date
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