HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 815 JOHNSON STREET 6/10/2024 \ Commonwealth of Massachusetts -� ,Yruf nee An �yer
w City/Town of
System Pumping Record SUN 10 2024
Form 4
DEP has provided this form for use by local Boards of Health. Othersk� y 31 e OP-81e 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. L r L t
HOUSE: front ac sid re eft right
A. Facility Information BUILDING: front back side rear left right
Important:when DECK: under
filling out forms 1. System Location: S l
on the computer, r 3 /�q�` (-
use only the tab )
key to move your Address
cursor-do not N'J\A( J+r MA
use the return Cit !Town
key. y State Zip Code
2. System Owner:
-_� Name
rn�rn
Address(if different from location)
MA
__
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 3 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:
N'dr(--,1
6. System Pumped By:
Dave Tiney Mass 1AA95E ss 1AD 1 _
Name Vehicle I-icense Number
Bateson Enterprises, Inc.
Company
7. ^T where contents were disposed:
�GLSDJI
� 6I31�y
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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