HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 103 BRADFORD STREET 8/5/2024 Commonwealth of Massachusetts a°�e�
City/Town of
a System Pumping Record 4 5`Loti°`
Form a\slForm 4
PEP has provided this form for use by local Boards of Health. Other forms m but the
information must be substantially the same as that provided here. Befor ` his form, check with your
local Board of Health to determine the form they use. The System PUWRecord 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 6a left' right
A. Facility Information BUILDING: front back side rear left right
Important:when DECK: under
filling out forms 1. System Location.-
on the computer, li�
use only the tab �j
key to move your Address cursor•do not N aA r MA �
use the return
key. city/Town State Zip Code
� P
2. System Owner:
C�t 24
Name
roan
Address (if different from location)
MA
Clty(rown State
Zip Code
q?-9- 6�-Y Gyyz
Telephone Number
B. Pumping Record
1. Date of Pumping 2� L
p 9 Date 2• Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
g El Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney M 49'5"lAA95 Mass 1AD31Z
Name Ve icle ! Icense Nu ber
Bateson Enterprises, Inc.
Company
l 7. nLt�ion where contents were disposed:
he z
Signature of Hauler Dale
Signature of Receiving Facility(orahach facility receipt) Date
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