HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 357 REA STREET 1/2/2024 Commonwealth of Massachusetts
r City/Town of . gti�ti
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 back side rear eft right
A. Facility Information BUILDING: front back sl a rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab 6-ec i—
key to move your Addres
cursor- not N l �a���
use the return
urn /V MA —t
key. City/Town State
Zip Code
2. System Owner:
Name
rerun
Address (if different from location) .
MA
city/Town
State� Zip Code
1��-s��_s2OZ
Telephone Number
B. Pumping Record
1. Date of Pumping �a
Date
p 9 2 --- 2. Quantity Pumped: I
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 pumped:
�bC M
6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA95
Name Vehicle License N ber
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
GLS
Signature of Hauler Date L
Signature of Receiving Facility(or attach facility receipt) Date
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