HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 61 ESSEX STREET 7/1/2024 Commonwealth of Massachusetts
Clty/Town of
System Pumping Record 0-
Form 4
DEP has provided this form for use by local Boards of Health. Other for ng Hed, but the
information must be substantially the same as that provided here. Before 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 bac side rear le right
A. Facility Information BUILDING: front back side rear left right
Important:when DECK: under
filling out forms 1. System Location: I
on the computer, G r ��Se�
use only the tab 1
key to move your Address
cursor• not MAuse
key the return
urn City/Town State Zip Code
2. Sys m Owner:
1 Name
Address (if different from location)
MA
Clty/Town State ZIP Code
Telephone Number
E3. Pumping Record
1. Date of Pumping Date !� 2 2• Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank g El Grease Trap
❑ Other (describe): ,(
4. Effluent Tee Filter present? ❑ Yes LL► No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed con ition of component pumped:
06CY
6. System Pumped.By:
Dave Tiney Mass 1AA95E Mas�1AD31Z
Name Vehicle License Num r
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
GLS
Signature of Hauler Dale
Signature of Receiving Facility(or,attach facility receipt) Date
15form4.doc• 11112 System Pumping Record-Page 1 of 1