HomeMy WebLinkAboutFailed - Septic Pumping Slip - 280 GRAY STREET 6/17/2024 Commonwealth of Massachusetts , ��o�
= City/Town of 1� tioti�
a _ System Pumping Record
L,M 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. /-tl
HOUSE: front c side rear left ig4t
A. Facility Information BUILDING: front back side rear left rig t
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address \
cursor-do not �` �� C ""A MA o I `�S
use the return key. City/Town State Zip Code
2. System Owner:
Na e
Address(if different from location)
MA
Cityrrown State Zip Code
yet-K' I
Telephonb Number
B. Pumping Record
1. Date of Pumping D -- 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? T Yes ❑ No If yes, was it cleaned? 4 Yes ❑ No
5. Observed condition of component pumped:
V'� , ;
6. System Pumped By: —�
Dave Tiney Mass 1 AA95E (Mass 1 AD31 Z)
Name Vehicle License Numbe
Bateson Enterprises, Inc.
Company
7. L c ion where contents were disposed:
rGLS
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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