HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 83 LIBERTY STREET 9/6/2024 ro
Commonwealth of Massachusetts
City/Town of 0
System Pumping Record
? Form 4 , -g,i•1 ��` �
PEP has provided this form for use by local Boards of Health. Other forms 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.
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HOUSE: front back side rear left right
A. Facility lnforrnatiorl BUILDING: back side rear left right
Important:when DECK: under
filling out forms 1. System Location:
on the computer, /
use only the lab Lr S
key to move your Address
cursor•do not L n 2d
use MA the return
key. CIIyfrown Stale
Zip Code
2. System Owner:
rnus Name
Address (if different from location)
MA
CIIyrrown Slate] Tip
�+-Code
Telephone Number
B. Pumping Record
1. Date of Pumping �' /SZO
p g Date 2 2• Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): /
4. Effluent Tee Filter present? ❑ Yes I/I No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed conditi n of component pumped:
6. System Pumped By:
Dave Tiney ass 1AA95E Mass 1AD31Z
Name ehicle License Numb r
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
i
GLS
Signature of Hauler bate
Signature of Receiving Facility(oretlach facility receipt) Dale
15form4.doc• 11112
Sys lem Pumping Record •Page 1 of 1