HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1659 OSGOOD STREET 6/10/2024 Commonwealth of Massachusetts -;€i . ,�")V i
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City/Town of
System Pumping Record SUN 10 M4
Form 4
DEP has provided this form for use by local Boards of Health. Otho`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 40ear left right
A. Facility Information BUILDING: front back side rear left right
Important:when DECK: under
filling out forms 1. System Location:
on the computer, /� l
use only the tab /('� aw L r
key to move your Addrea s v
cursor•do not �.own MA
use the return it !T
key. y State Zip Code
2. System Owner:
rn �� Gti1(O�-
Nam
man
Address(if different from location)
MA
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Da 3� 2. Quantity Pumped: Gallonw-
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 p,mped:
6. System Pumped By:
Dave Tiney Ma s 1AA95E Mass 1AD31Z
Name Vehi ber
Bateson Enterprises, Inc.
Company
7. cation where contents were disposed:
(G!LS
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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