HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 147 JOHNNY CAKE STREET 5/13/2024 Commonwealth of Massachusetts
= City/Town of
System Pumping Record
Form 4
M
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 r left right
A. Facility Information BUILDING: front back side rear ft right
Important:when DECK: under
filling out forms 1. System Locati n:
on the computer,
use only the tab
key to move your Addre s
cursor-do not o4r MA
use the return its yfrown �-- State Zip Code
key.
2. SysXem Ow e����
rya
Name
rerun ''
Address(if different from location)
MA
Cityfrown State ` J ip Fode
Telephone Number
B. Pumping Record '
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Ye o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA9 Mass 1AD31Z---
Name Vehicle Licen Numb
Bateson Enterprises, Inc.
Company
7. Location ontents were disposed:
G
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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