HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 18 JOHNNY CAKE STREET 3/15/2024 Commonwealth of Massachusetts
^ it System Pumping
y umping Record M
Form 4 ��t
DEP has provided this form for use by local Boards of Health. Other fory-be used, but the
information must be substantially the same as that provided here. Befor 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: fron back side rear left right
A. Facility Information BUILDING: front ack side rear left right
Important;When
DECK: under
filling out forms 1. System Location:
on the computer,use only the lab (QO—
�A A`/ Cc, Q
key to move your Add ess
cursor•do not "NON(�vtj—
MA
use the return
key. City/Town State Zip Code
„e
2. System Owner:
S64A C.,
Name
nnm
Address (if different from location) .
MA
Cily/Town State,,,_ � Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping o3ee Y 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): TT
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? [IYes ❑ No
5. Observed condition of component pu ped:
6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA95
Name Vehicle License N mber
Bateson Enterprises, Inc.
Company
7, tion where contents were disposed:
GLS
3 L
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
15form4.doc- 11/12
System Pumping Record-Page 1 of 1
