HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 120 GRAY STREET 3/27/2024 Commonwealth of Massachusetts
City/Town ofy �� tioti�
System Pumping Record MPS ��rti
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 side rear left QrightA. Facility Information BUILDING: rout back side rear left
Important;When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Ad Ay
cursor-do not � MA
use the return key. Cily/Town Stale Zip Code
r�
2. System Owner:
Man t c� \ ers
Name
rvnrn
Address (if different from location) .
MA
City/Town Slate Zip Code
Lif a - 9 o�--2 �_6y
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: J5�
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 condition of component pumped:
Ndr A^" I
6. System Pumped By:
Dave Tiney Mass F5821 ass 1AA
Name Vehicle License Nu ber
Bateson Enterprises, Inc. _
Company
7. Le6Q,,tion where contents were disposed:
GLSO
dA'
Signature of Hauler Dale
Signature of Receiving Facility(or attach facility receipt) Dale
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