HomeMy WebLinkAboutPump Chamber - Septic Tank - Septic Pumping Slip - 220 BOXFORD STREET 7/29/2024 Commonwealth of Massachusetts
_ City/Town of
System Pumping Record JUL 2 9 2024
Form 4
/ b
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 rea eft right
A. Facility Information BUILDING: front back side r left right
DECK: under
Important:When
filling out forms 1. S tem Location
on the computer, �-
use only the tab
QA
key to move your dres
cursor-do not C MA
use the return City/Town State Zip Cod
key.
2. Sy m Owner:
° N me
renm
Address(if different from location)
MA
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
X"Other(describe): l
4. Effluent Tee Filter present? ❑ Yes , No If yes, was it cleaned? ❑ Yes ❑ No
5. Ob ed cond' ion of component pumped:
�
6. System Pumped By:
Dave Tiney �- -Mh—iclse
asName Licen er
Bateson Enterprises, Inc.
Company
7. ion ere contents were disposed:
GLSD
Signature of Haul Date
Signature of Receiving Facility(or attach facility receipt) Date
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