HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 520 BOSTON STREET 1/2/2024 Commonwealth of Massachusetts
City/Town of
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 CMR 15.351.
HOUSE: front back side rear left right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, SV
use only the tab
key to move your Address
cursor- not /�"
use the return
urn / �e� MA
key. Cityrrown State
Zip Code
2. System Owner:
C-)o(-tJc>-'\ S
Name
Address(if different from location) .
City/Town MA
State O Zip Code
1�-O
Telephone Number
B. Pumping Record
1. Date of Pumping Date Ifflo-
2 Quantity Pumped: J��
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 conditio of component pumped:
6. System Pumped By:
Dave Tiney
M icle ense Nu berass F5821
Name Veh Lic Mass 1AA95
B ateson Enterprises Inc.
Company
7. c 'on where contents were disposed:
GLSD
Signature of Hauler
Date
Signature of Receiving Facility(or attach facility receipt) Date --
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