HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 455 CHESTNUT STREET 4/17/2024 ao�th An o
vel
Commonwealth of Massachusetts 2024
City/Town of APR 1
System Pumping Record
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 ack side rea 0right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location: r ��
on the computer,
use only the lab
key to move your A res
cursor•do not 1 / (T&A_ MA ��& •��
use the return �'"�
key.
Cilyrrown Stale Zip Code
2. System Owner:
r�
Name
Address (it different from location).
MA
CilyrTown Stale �j yZip Code
\'4& �591 -53El
Telephone Number
B. Pumping Record
1. Date of Pumping Dad3e -- 2. Quantity Pumped: GallonsO�
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tank Tight
g ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed conditi n.of component pumped:
6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA95
Name Vehicle License Nu ber
Bateson Enterprises, Inc.
Company
7, where contents were disposed:nn
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipl) Dale
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System Pumping Record•Page 1 of 1