HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 425 BOXFORD STREET 12/21/2023 x
IL'\ Commonwealth of MassachLasetts
City/Town of
ti0
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: fron back side rear left right
A. Facility Information BUILDING: back side rear left right
Important:When
DECK: under
filling out forms 1. System Locatio
on the computer, yts
use only the tab
key to move your Address
cursor-do not �1 wdV"V MA C �+
use the return city
/Town
key. y State Zip Code
2. SystemOwner:
Name
nnm
Address(if different from location) .
MA
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping I? — 2. Quantity Pumped:
Date 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 p ped:
- llJ� ` -- —
6. System Pumped By:
Dave Tiney Mass F5821 ass�19
Name Vehicle License Num er
Bateson Enterprises, Inc.
Company
7, tion where contents were disposed:
GL
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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