HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 28 JERAD PLACE 7/1/2024 Commonwealth of Massachusetts
City/Town of
x System Pumping Record
a r
Form 4
e
DEP has provided this form for use by local Boards of Health, Other forms ITAo�txsed, but the
information must be substantially the same as that provided here. Before usi g 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: Gn back side rear left(right
A. Facility Information BUILDING: front back side rear left right
Important:when DECK: under
filling out forms 1. System Location:///^✓���1
on the computer,
use only the tab U
key to move your Address
cursor-do not '—V ` MA
use the return it !Town
key. y Slate Zip Code
2. System Owner: `
Name
roan
Address(if different from location)
MA
City/Town State Zip Code
ylo-LJ22- ?
Telephone Number
B. Pumping Record
1. Date of Pumping DateIfs L 2. Quantity Pumped: /5�)
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 condition of component pumped:
IU�rr<<
6. System Pumped By:
Dave Tiney Mass 1AA95E Mass 1A631Z
Name Vehicle License Numb
Bateson Enterprises, Inc.
Company
7. 1 acation where contents were disposed:
CLSD
ce fF,Z
Signature of Hauler Dale
Signature of Receiving Facility(or attach facility receipt) Date
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