HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 439 WINTER STREET 8/26/2024 Commonwealth of Massachusetts
City/Town of
i ° i
System Pumping Record ��
e
Form 4
DEP has provided this form for use by local Boards of Health. Other forms maybe used, but the
information must be substantially the same as that provided here. eefore.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: fron back side rearqeright
A. Facility Information BUILDING: front ack side rearright
Important:when DECK: under
filling out forms 1. System Location:
on the computer, V l , ` L C J`1
use only the tab (�1/l j"
key to move your Address
cursor-do not MA I ta5 use the return - ---
key. City(rown State Zip Code
2. System Owner:
Name
anm
Address (if different from location)
MA
Cllyrrown State ��.J Zip Code
p
la's-g7 / 6
Telephone Number
B. Pumping Record
1. Date of Pumping pate ' 2• Quantity Pumped:
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:
6. System Pumped By:
Dave Tiney ass 1AA95E:�, Mass 1AD31Z
Name Ve le license Nu er
Bateson Enterprises, Inc.
Company
7. mct' n where contents were disposed:
�I iS�2Y
Signature of Hauler Date
Signature of Receiving Facility(oratlach facility receipt) Date
15form4.doc• 11112 System Pumping Record -Page 1 of 1
