HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 767 JOHNSON STREET 3/15/2024 Commonwealth of Massachusetts
City/Town of
2024
System Pumping Record BAR 15
Form 4 t
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 e right
A. Facility Information BUILDING: front back si e rear le right
Important:When DECK: Under
filling out forms 1. System Location:
on the computer,
use only the lab
key to move your Address
cursor- not
use the return
urn U� MA �1 U l�
key. CilylTown
State Zip Code
Q
2. System Owner:
rvame J
nnm
Address (ir dtfferenl from location) .
Cily/Town MA
Stale Zip Code
B. Pumping Record Telephone Number
1, Date of Pumping
oate 2. Quantity Pumped:
Gallons
i 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 con ition of component pu ped:
6. System Pumped By:
Dave Tine
Name Mass F5821 Mass 1AA95
Bateson Enterprises Inc vehicle License umber
Company
7. on where contents were disposed:
GLSD
Signature of Rauler Z�
Oale
Signature of Receiving Facility(or allach facility receipt) Date
l5formel.doc- 11112
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