HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 196 SUMMER STREET 12/21/2023 Commonwealth of Massachusetts .
City/Town of
Z j
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: fro back side rear left right
A. Facility Information BUILDING: rout back side rear right
Important:When DECK: under
filling out forms 1• System Location.
on the computer, 1�
use only the tab U f-•o" S
key to move your Address
cursor- not
use the return
urn �" L)'�� MA
key. CityfTown State
Zip Code
2. System Owner:
M4rc_
Name
nnm
Address(if different from location) .
MA
CityfTown
State Zip Code
Co k -44 Z32S
Telephone Number
B. Pumping Record
1. Date of Pumping ll 1( 2. Quantity Pumped: /Sn) _
Da e y pedGallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present?/
resent? YesNo If yes; was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass F5821 ass 1AA95
Name
Vehicle License Nu ber
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
GLSD
Signature of Hauler — ' It 17
Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.docr 11/12
System Pumping Record•Page 1 of 1