HomeMy WebLinkAbout- Septic Pumping Slip - 104 COLONIAL AVENUE 4/17/2024 k
Commonwealth of Massachusetts
City/Town of
a
System Pumping Record °R 17 ZU4
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.
A. Facility Information
Left fight r nt of house, Left/Right rear of house, Left/Right side of house, Under[
Important:When
filling out forms 1. System Locatio : Left/ Right side of building, Left/ Right front of building, Left/Right rear of building,
on the computer,
use only the tab `
key to move your Address
cursor-do not MA
use the return CTtyrrown State Zip Code
key.
2. S tem Owner:
Name
kenm
Address(if different from location)
MA
CitylTown State V3n ip Cod
Telephon Number �v(
B. Pumping Record Y�Q
`''C�� Pumped'. )Slid-
1
. Date of Pumping Date 2 Quantity p 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 AA 1,}4 9/5Q
Name Vehicle License Dfumber
Bateson Enterprises, Inc.
Company
7. ocation ere contents were disposed:
GL
Signature of r Date
Signature of Receiving Facility(or attach facility receipt) Date
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