HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 480 Boxford Street 3/29/2024 Commonwealth of Massachusetts
City/Town of
x System Pumping Record P��9
Form 4 M >A
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 usg' his form, check with your
local Board of Health to determine the form they use. The System Pumping ecord 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( rear left right
A, Facility Information BUILDING: front backrear left n
Important:When
DECK: under
filling out forms 1. System Location:
on the computer,
use only the lab
key to move your Addr ss
cursor-do not . MA
use the return -- -------- T
key.
Cily/Town Stale Zip Co e
r�
2. System Owner.
Name
nnm
Address (if different from location) .
MA
city/Town Stale Zip Code
Telephone Number
B. Pumping Record
40-
1. Date of Pumping Z gate 2. Quantity Pumped: 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 p mped:
0,�c
6. System Pumped By:
Dave Tiney Mass F5821 ass 1AA95
Name Vehicle License Num er
Bateson Enterprises, Inc.
Company
7. ror, ion where contents were disposed:
Signature of Hauler Dale
Signature of Receiving Facility(or attach facility receipt) Dale
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