HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1175 TURNPIKE STREET 6/10/2024 Commonwealth of Massachusetts �N 0 2024
City/Town of
a System Pumping Record
t
Form 4
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 rear left right
A. Facility Information BUILDING:e-f-ro-n7j>back side rear left right
Important:when DECK: under
filling out forms 1. System Location:
on the computer, n� `
use only the tab I( 7'`, jur'nD t e 5T
key to move your Address
cursor-do not /i �a��� MA l�`1Sr use the return Cil (Town
key. y State Zip Code
2. System Owner:
raD
,ry ep, 1 SL l4 f
Name
man
Address(if different from location)
MA
Clty/Town State
ZI Code
Telephone Number
B. Pumping Record
30 2
Date � 2. Quantity Pumped: � 0
1. Date of Pumping
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:
Oor
6. System Pumped By:
Dave Tiney Mas rlAA95E Mass 1AD31Z
Name Vehlcl l,lcense N ber
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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