HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 193 GRAY STREET 8/5/2024 Commonwealth of Massachusetts doV0
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System Pumping Record
Form 4 oa�p Oti
PEP has provided this form for use by local Boards of Health. Other forms may be used,
information must be substantially the same as that provided here. Before usin t�s check with your
local Board of Health to determine the form they use. The System Pumpord 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 rea le ' right
A. Facility Information BUILDING: front back side rear left right
Important:when DECK: under
(filing out forms 1. System Location:
on the computer. I qt>
use only the lab 7G�t�J � -
key to move your Address
cursor-do not A) At\ MA
use the return
key. Cily/Town Slate Zip Code
2. Syste Owner:
y
a Name
arun
Address (if different from location)
MA
Cllyrrown Stale Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 1 2• Quantity Pumped.
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
g ❑ 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 Ma s 1AA95E Mass 1AD31Z
Name Vehi le t lcense N bet
Bateson Enterprises, Inc.
Company
7, (Z`cWkn where contents were disposed:
GLSD
Signature of Hauler Dale
Signature of Receiving Facility (or,atlach facility receipt) Dale
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