HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 970 JOHNSON STREET 12/21/2023 (2) Commonwealth of Massachusetts
u City/Town of �1ti0
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 ack side rear left right
A. Facility Information BUILDING: front bac side rear left right
Important:When
DECK: under
filling out forms 1. System Location:
on the computer, S70 '5 1
use only the tab 7C/ }—
key to move your Address
cursor-do not \ Q o MA C)I y�
use the return Cit—/Town
key. y State Zip Code
VIQ 2. System Owner:
Name
rerun
Address(if different from location).
MA
CitylTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
)DOO
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 p ped:
IUoc-rt
6. System Pumped By:
Dave Tiney - Mass F5821 ass 1AA95
Name Vehicle License Num r
Bateson Enterprises, Inc_.
Company
7, ation where contents were disposed.-
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
I
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