HomeMy WebLinkAbout- Septic Pumping Slip - 475 WINTER STREET 6/17/2024 Commonwealth of Massachusetts �h P�ao�et
City/Town of � �`�
System Pumping Record TV
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 fro ack side rear left right!
A. Facility Information BUILDING: front back side rear left
Important:when DECK: under
filling out forms 1. ?dd
tem Loc tion:
on the computer,
use only the tab 6
key to move your ess /
cursor-do not ftc&MMA D "/
use the return
key. ity/Town State Zip Code
2. S tem Owner:
Name
Address(if different from location)
MA
City/Town State
Telephone`Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of�c/onmponen pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E ass 1AD31Z
Name Vehicle License r
Bateson Enterprises, Inc.
Company
7. atio here contents were disposed:
:GLD
Signature of Ier Date
Signature of Receiving Facility(or attach facility receipt) Date
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