HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 858 JOHNSON STREET 1/2/2024 Commonwealth of Massachusetts
City/Town of
a System Pumping Record LPN
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 CM 15.351.
HOUSE: front bac side rear �Ieftnght
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 �
key to move your Ad res
cursor-do not MA V I6(a
use the return Cit /Town V
key. y State Zip Code
rab 2. System Owner:
Name
renm
Address(if different from location) .
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 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 condi 'on of component pumped:
6. System Pumped By:
Dave Tiney Mass F5821 Mass 1 AA95
Name Vehicle License N ber
Bateson Enterprises, Inc.
Company
7. o tion where contents were disposed:
GLSD
22 u Z
Signature of Hauler Date -
Signature of Receiving Facility(or attach facility receipt) Date
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