HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 268 REA STREET 5/21/2024 Commonwealth of Massachusetts ° Rn�o�et
C ity/Town ofs=
System Pumping Record
Form 4
M ,
DEP has provided this form for use by local Boards of Health. Other for, rVay qe used, but the
information must be substantially the same as that provided here d41sing 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: fro back side rear left ight
A. Facility Information BUILDING: fron side rear left right
Important:when DECK: under
filling out forms 1. System Location:
on the computer, S
use only the tab 2&8- Qecx
key to move your AVs
cursor-do not MA
key.
use the return CitylT'own State Zip Code
2. S stem Owner:
Name
/N671
Address(if different from location)
MA
Clty/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping It
Is
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:
I"0QAk -- - --
6. System Pumped By:
Dave Tiney Mass 1AA95E Mas�MD31Z
Name Vehicle License Num r
Bateson Enterprises, Inc.
Company
7. on where contents were disposed:
( )GLSD
Signature o auier Date
Signature of Receiving Facility(or attach facility receipt) Date
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