HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 889 JOHNSON STREET 6/10/2024 Commonwealth of Massachusetts
City/Town of JUN 10 2024
System Pumping Record
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: rcnt back side rear left right
Important:when DECK: under
filling out forms 1. System Location:
on the computer, �\ C
use only the tab 1r1(lsO,r� J
key to move your Address
cursor- not ). �L}� MA
use the return
urn Cit !Town
key. y State Zip Code
2. System Owner:
Name
ieluW
Address (if different from location)
MA
Clty/Town State Zip Code
���--�21�Ge
Telephone Number
B. Pumping Record
1. Date of Pumping
p g 2. Quantity Pumped:
Date
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
g ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Ma 1AA95E Mass 1AD31Z
Name Veh cle License umber
Bateson Enterprises, Inc.
Company
7. oc ' n where contents were disposed:
GLS DY
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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