HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 63 BRADFORD STREET 3/15/2024 Massa oCommonweal h f __chusetts
t
City/Town of
a System Pumping Record MPR15 ti�1
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 bac side relre right
A. Facility Information BUILDING: front back side rear left right
Important:When
DECK: under
filling out forms 1. System Location.
on the computer, /�^^ 2 C I 1
use only the tab cog � f C. rl S l
key to move your Address
cursor-donot MA
' use the return
urn
key. Cily[Town Slate Zip Code
„e
2. System Owner: II II
1 'C\02n /"e s
Name
nnm
Address(if different from location) .
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
aQ
1. Date of Pumping at LN 2. Quantity Pumped: Gail
ons
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 p mped:
cwt-.'C l
6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA9
Name Vehicle License N mber
Bateson Enterprises, Inc.
Company
7. koltion where contents were disposed:
GLSE)
J�rD lo
Signature of Hauler Dale
Signature of Receiving Facility(or attach facility receipt) Date
15form4.doc- 11/12
System Pumping Record•Page 1 of 1
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