HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 15 BRADFORD STREET 8/26/2024 Commonwealth of Massachusetts
City/Town of
System Pumping Recordr;�
Form 4 c �6ti
DEP has provided this form for use by local Boards of Health. Other forms may be used, but t "�� '�
information must be substantially the same as that provided here. Before using this farm, gh6ck 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: frontPack
side re left' right
A. Facility Information BUILDING: frontside rear right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, 13 n c,,�� r-q
�-}
use only the tab f,� -
key to move your Address
cursor•do not t? — MA
use the return CII !Town
key. y State Zlp Code
011
2. System Owner:
Name
Address (if different from location)
MA
Cltyrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date�)� 2 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank g ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ YestNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component ped:
iJlsCr�.�
6. System Pumped By:
Dave Tiney Mass 1AA95E ass 1AD31Z
Name Vehicle License Numb r
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
GLS
Signature of Hauler Dale
Signature of Receiving Facility(o(•attach facility receipt) Date
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