HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 305 ABBOTT STREET 3/27/2024 aoyet
Commonwealth of Massachusetts
City/Town of
F ° System Pumping Record
Form 4 der
DEP has provided this form for use by local Boards of Health. Other forms ma .".a but the
information must be substantially the same as that provided here. Before u!rl� is 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: (FoEn�tback
back side rear left rig
A. Facility Information BUILDING: side rear left right
Important:When
DECK: under
filling out forms 1. System Location:
on the computer, X>�
use only the lab
key to move your Address
cursor-do not . y
use the return N - MA
key. Ci y/Town Slate Zip Code
2. System Owner:
,� �;O, T 1_11JG
Name
ratan
Address (if different from location) .
MA
City/Town Slate Zip Code
Telephone Number
B, Pumping Record ��77
1. Date of Pumping p`� f 2 1 2. Quantity Pumped: !sue
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 con ition of component p mped:
6. System Pumped By:
Dave Tiney Mass F5821 ss 1AA95E
Name Vehicle License Numbe
Bateson Enterprises, Inc.
Company
7. lion where contents were disposed:
GLS
3�ts 2�
Signature of Hauler Dale
Signature of Receiving Facility(of attach facility receipt) Date
15form4.doc- 11/12
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