HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 450 BOSTON STREET 4/17/2024 Commonwealth of Massachusetts
City/Town of ApR 17 2024
System Pumping Record
Form 40 ��t,�r✓nt
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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 right
A. Facility Information BUILDING: front back side rear left right
Important:When
DECK: under
filling out forms 1. System Location:
on the computer, ri,r� S 1
use only the lab
key to move your Address 1,
cursor-do not �C6C MA 45
use the return !
key. Cilyrrown Stale Zip Code
VQ 2. System Owner:
it I- r" S41CM0r%,4;
Name
r�nrtm
Address (if different from location) .
MA
Cilyrrown Slate Zip Code
qP I -
Telephone Number
B. Pumping Record
1. Date of Pumping A �2I ----
p g Date 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 pumped:
6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA95E
Name Vehicle License Number
Bateson Enlerprises, Inc.
Company
7, nb'
n where contents were disposed:
Signature of Hauler Dale
Signature of Receiving Facility(o(allach facility receipt) Oale
15form4.doc- 11/12
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