HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 623 OSGOOD STREET 9/6/2024 Commonwealth of Massachusetts
City/Town of
`i
a
System Pumping Record ''''``
Form 4 �
DEP has provided this form for use by local Boards of Health. Other forms m rbut the
information must be substantially the same as that provided here. Before us4noti 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 -he 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:
onnthe computer,
use only the tab
key to move your WreW
cursor-do not MA
use the return It/w�
key. y y State Zip Code
2. System Owner:
u5
a d� Name
Irllvp
Address (if different from location)
MA
City/Town Slate Ip Code
Telephone Number
B. Pumping Record
I,&d-
1. Date of Pumping D e 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4, Effluent Tee Filter present? ❑ Yes VNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E Mass 1AD31Z
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed.
GLSD
Signature of H Date
Signature of Receiving Facility(or attach facility receipt) Date
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