HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 313 SUMMER STREET 5/13/2024 e r t"1
Commonwealth of Massachusetts MAY 13 NZ4
City/Town of
System Pumping Record ,� Department
Form 4
�M Sr
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 left right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, r
use only the tab 5'
`-4-M
key to move your Address
cursor-do not AAd,(j u—k, MA V b J�
use the return City/Town State Zip Code
key.
2. System' Owner: /
Name
ie�un
Address(if different from location)
MA
City/Town State Zip Code
cas--(0 Y�
Telephone Number
B. Pumping Record
1. Date of Pumping Dat 2 2. Quantity Pumped: Galion
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 conditi n of component pumped:
h 0'r t -�_ — — --- ---
6. System Pumped By:
Dave Tiney Mass 1AA95E Mass 1AD31Z
Name Vehicle License Nu ber
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
GLSD
0 '5h-h
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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