HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 380 BOXFORD STREET 4/29/2024 r
Commonwealth of Massachusetts
City/Town of p,pR 2 9 2�24
System Pumping Record
Form 4 t
DEP has provided this form for use by local Boards of Health. Other formsl-r ;"'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
[he local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
HOUSE: fron bac side rear left 'ght
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, ( ^�
use only the lab o �C L J
key to move your A`Cs
s
cursor•do not MAuse the return
key. Cilyrrown Stale Zip Code
2. System Owner:
f <<,
Name
nnm
Address (if diMerenl from location) .
MA
cilyrrown Slate Zip Code
Telephone Number
B. Pumping Record `
1. Dale of Pumping oal i 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes [ No It yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition ofcomponent pumped:
6. System Pumped By:
Dave Tiney Mass F5821
Name Vehicle License N(EAAD
Bateson Enterprises, Inc.
Company
7. gonwhere contents were disp`sed:
Signature of Raulef Dale
Signature of Receiving Facility(or attach facility receipt) Dale
l5form4,doc 11/12
System Pumping Record Page 1 of 1