HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 731 JOHNSON STREET 5/21/2024 ao�et
Commonwealth of Massachusetts
C ity/Town of MP,i 1 ti�ti�
a
System Pumping Record t
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 ear left®rig�h
A. Facility Information BUILDING: front back si e rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab � _ __--
key to move your Addres
cursor-do not b - MA
use the return City/Town State Zip Code
key.
2. System Owner:
F--11 �k LA
Name
reran
Address(if different from location)
MA
City/Town State Zip Code
II�; -q� S
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? ❑ Yes ] No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
l)arM,(
6. System Pumped By:
Dave Tiney _ Mass 1AA95E ass 1ADM-f
Name Vehicle License Num er
Bateson Enterprises, inc.
Company
7. ion where contents were disposed:
GLS _
Signature of Hauler Date
Signature of Recewing Facility(or attach facility receipt) Date
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