HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 53 BROOKVIEW DRIVE 4/17/2024 Commonwealth of Massachusetts APR 17 2024
City/Town of
System Pumping Record i.ent
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 back side rear oleftright
A. Facility Information BUILDING: front side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, Q2 �^
use only the lab srco tl U l�
key to move your Address
cursor•do not ) Q„ �„��� MA
use the return —,.Aa(6
key.
Cm
State Zip Code
2. System Owner:
Name
nMn
Address (if different from location).
MA
Cilyrrown Stale Zip Code
Telephone Number
B. Pumping Record o
1. Date of Pumping `} 2� ZY 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) [� Septic Tank ❑ Tight Tank/ g [I Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes /No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition.of component pumped:
i
6. System Pumped By.-
Dave Tiney Mass F5821 Mass 1AA9
Name Vehicle License Nu ber
Bateson Enterprises, Inc.
Company
7. Lo lion where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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