HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 145 BRADFORD STREET 5/24/2024 Commonwealth of Massachusetts �naovet
_ . C ity/Town of
a System Pumping Record 4
Form 4 MPS
DEP has provided this form for use by local Boards of Health. Other forms maybe used buf the
information must be substantially the same as that provided here. Before using this-forFn, check with your
local Board of Health to determine the form they use. The System PUrnoing 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: fron ,back�rearright
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. S717
stem Location:
on the computer, 7� eAv b C,n 6 SIX
use only the tab �J' � L J � "�'� uJ /l
key to move your Address , a � v
cursor-do not �j� MA
use the return City/Town State Zip Code
key.
2. Sy.stem Owner:
Name
Address(if different from location)
_ MA
City/Town State ip Code-z.
Telephone Number T
B. Pumping Record l
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 No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component p mped:
6. System Pumped By:
Dave Tin_ey — j. hicle
ass 1AA95E $s 1AD31Z
Name License Nu
Bateson Enterprises, Inc.
Company
7. Lo ton ere contents were disposed:
GLSD
1z
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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