HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 VEST WAY 7/1/2024 Commonwealth of Massachusetts �dpVe�
City/Town of
System Pumping Record �pwp
Form 4
PEP has provided this form for use by local Boards of Health. Other forms may be us w'ti��r
information must be substantially the same as that provided here. Before using " I check with your
local Board of Health to determine the form they use. The System Pu��� -Ve'cord must be submitted to
the local Board of Health or other approving authority within 14 days IIX the pumping date in
accordance with 310 CMR 15,351.
HOUSE: front ack side rear left rig
A. Facility Information BUILDING: Pont back side rear left rig t
Important:when DECK: under
filling out forms 1. System Locgon:
on the computer, / /1
use only the lab `� `
key to move your Address
cursor-do not
use the return e�--- ----
MA
key. CilylTown Slate Zip Code
2. System Owner:
v
e\ Name — --- - -—-
iellm
Address (If different from location)
MA
Cltyrrown State Zip Code
/-,)^N
Telephone Number
B. Pumping Record
1. Date of Pumping Date O 2 2. Quantity Pumped: Gallons
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 cond'tion of component pumped:
0('rrk
6. System Pumped By:
Dave Tiney Mass 1AA95E Mass 1AD31Z
Name Vehicle t,icense Nu ber
Bateson Enterprises, Inc.
Company
7. 'on where contents were disposed:
GLSD
Signal re of Hauler Date
Signature of Receiving Facility(orattach facility receipt) Date
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