HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 21 EASY STREET 3/27/2024 J•5' •,`,F
Commonwealth of Massachusetts
w City/Town of ��tioti
x System Pumping Record MPS erg'
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' i'sing 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 ack side rear le right
A. Facility Information BUILDING: back side rear left
Important:When
DECK: under
filling out forms 1. System Location:
on the computer, 21 Y ��
use only the tab
key to move your Add e s
cursor-do not .rls,�&Uv, MA
use the return Cil /Town
key. y State Zip ode
2. ��Mef
em Owner-
,� c
Name
nnm
Address(if different from location) .
MA
City/Town State Zip Code
G I`-I- 4
Telephone Number
B. Pumping Record
1. Date of Pumping at Z( 2. Quantity Pumped: �s^
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 cond'tion of component pumped:
Uc ,mq
6. System Pumped By:
Dave Tiney Mass F5821 Mas�195E
Name Vehicle License Nu ber
Bateson Enterprises, Inc.
Company
7. n where contents were disposed:
GLSD
l
Signature of Mauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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