HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 337 HILLSIDE ROAD 8/26/2024 Commonwealth of Massachusetts
City/Town of _ g'
System Pumping Record A
Form 4 , _;•��. ;�'"�`��'��
PEP has provided this form for use by local Boards of Health. Other fo'im_. s 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 side rear 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. �._ 411 1S`.(C 1 t
use only the tab -j 1 C t
key to move your Address
cursor-do not MA (� I L���
use the return
key. Cuyfrown Stale Zip Code
2. System Owner:
rd 1�
C C'!1 n C C 167 0oiC3S
1 Name
rerun
Address (if different from location)
MA
Cllyrrown ---- Slate
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping oat 2 Z 2-`� 2. Quantity Pumped: A5cxf
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
/ g ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes 4 No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
IVaJ`M�,(
6. System Pumped By:
Dave Tiney 099)
Mass 1AD31Z
Name Vber
Bateson Enterprises, Inc.
Company
7. cation where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(orettach facility receipt) Date
t5form4.doc• 11/12
System Pumping Record •Pale 1 0l 1