HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 273 REA STREET 6/17/2024 ���Pad°Vet
�LN Commonwealth of Massachusetts J°WI,\o�
City/Town of
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
1 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�fronnt ack side rear left rig
A. FacilityInformation BUILDING: wont back side rear left right
Important:When DECK: under
filling out forms 1. S stem Loca 'on:
on the computer, f
use only the tab
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cursor-do not ZAP4 MA
use the return 'City/Town State 4Zipodi
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2. stem Owner:
Name
enrn
Address(if different from location)
MA
j Cityrrown State q./?i ode
Telephone Number
B. Pumping Record
1. Date of Pumping Date Lj
V 2. Quantity Pumped: Galion )
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Ye No If yes, was it cleaned? ❑ Yes [INo
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E Mass 1AD31Z
Name Vehicle License Nu
Bateson Enterprises, Inc.
Company
7. Location where conte is were disposed:
GLS
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Signature&HaLIA& Date
Signature of Receiving Facility(or attach facility receipt) Date
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