HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 80 BOSTON STREET 7/29/2024 _ P�ao�er
Commonwealth of Massachusetts 1o0\"�\,0�r
City/Town of q tioti�
a
System Pumping Record
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: front back sid rear left right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. SyAtem Location:
on the computer, S�
use only the tab
key to move your Adaress f ��
cursor-do not MA "1
use the return ityrrown State Zip Code
key.
2. System Owner:
—o—"-- —
Name
reran
Address(if different from location)
MA
City/Town State /��� � „ dip Code
Telephone Number �(!/l/S�C_
B. Pumping Record
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1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Qeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present?, Yes ❑ No If yes, was it cleaned? (§k/Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E ass 1AD31Z ,
Name Vehicle License Nurrker
Bateson Enterprises, Inc.
Company
7. L atio ere contents were disposed:
GLSD
Signature of Hau Date
Signature of Receiving Facility(or attach facility receipt) Date
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