HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 174 BRADFORD STREET 3/29/2027 Commonwealth of Massachusetts
City/Town of 9 tioti�
a System Pumping Record MpR �
Form 4 °P{j�
a
d..�,
DEP has provided this form for use by local Boards of Health. Other forms may 66'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 0side rear Peright
ight
A. Facili Information BUILDING: front back side rear
Important:When DECK: under
filling out forms 1. System Location:
on the computer, c
use only the lab � t_ L J
key to move your A dress
cursor-do not � MA
use the return
key. Cily/Town Slate Zip Code
2. System V
er:
na
Name
nnm
Address (if different from location).
MA
city/Town Stale Ct 7& Zip Code
Telephone Number
B. Pumping Record
1. Dale of Pumping Dale Z 2• Quantity Pumped: Gallon
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 pu/mped:
Ado(-A"t
6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA9
Name Vehicle License umber
Bateson Enterprises, Inc.
Company
7. lion where contents were disposed:
GLS
2
Signature of Hauler Dale
Signature of Receiving Facility(or attach facility receipt) Date
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