HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 550 BOXFORD STREET 4/29/2024 Commonwealth of Massachusetts
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Form 4 pp�
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
Le ght nt of house,. Left/Right rear-of house, Left/Right side of house, Under C
Important:t:When
fillingng out forms ? System Location: Left g t 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 -
key. ity/Town State Zip Code
2. Sy m Owner:
Address(if different from location)
MA
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TelephbT16 Number V J R. Pumping RecordV,if C6
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1 Date of Pumping Date - - 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): --- -- --- ---
4. Effl�_ient Tee Filter present? ❑ Yesa If yes, was t cleaned? ❑ Yes [l No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass F5821
Name vehicle License umber
Bateson Enterprises, Inc.
Company
7. Loca ' re contents were disposed:
- --
Signature of Hauler Date
$inn a{uie >f F r'—c wving rAi;ility(Oi Ailat;'h fadlity roc6ol)
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