HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 129 CHRISTIAN WAY 3/15/2024 o�et
Commonwealth of Massachusetts
w City/Town of MPR 15102�
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 �deear left�righA. Facility Information BUILDING: ront back ear leftg
Important:When
DECK: under
filling out forms 1. System Locatio
on the computer, a�, 'L,
use only the lab ,S �1..�
key to move your Ad res }
cursor•do not �( Je/ MA
use the return key. CityfTown Slate Zip Code
2. System Owner:
r� \\ )
Name j zV
rvnm
Address (if different from location) .
MA
City/Town State Zip Code
2d3-ybL-b_U?X
Telephone Number
B. Pumping Record
Itc
1. Date of Pumping Date y p 2. Quantit Pum ed:
Date Gallons
3. Component: ❑ Cesspool(s) JSeptic 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: /
l��we!`-
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:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Dale
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