HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 322 BOSTON STREET 7/1/2024 Commonwealth of Massachusetts
= City/Town of
System Pumping Record 01-a1 ���
Form 4
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DEP has provided this form for use by local Boards of Health. Other forms m y tg,,tlr T, but the
efore
information must be substantially the same as that provided here. B usil %lis 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 ac side rear leftright
A. Facility Information BUILDING: front back side rear left right
Important:when DECK: under
filling out forms 1. System Location.
on the computer, 2 n
use only the tab 32` GS
key to move your Address
cursor- not �1 ���� MA
use the return
urn City/Town State
key. Zip Code
2. System Owner:
Name
nrtm
Address(if different from location)
MA
CIIyrrown Slate Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date I r 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank g El Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? 0 Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E Kass 1AD31Z
Name Vehicle License Numbe
Bateson Enterprises, Inc.
Company
7. nLtion where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility(orattach facility receipt) Date
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