HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1000 JOHNSON STREET 9/6/2024 Commonwealth of Massachusetts `c `>
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Form 4 (`��
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DEP 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.
HOUSE: front ac side rear left'qrilgzt
A. Facility Information BUILDING: front back side rear left
Important:when DECK: under
filling out forms 1. System Location:
on the computer, .� C
use only the tab ��/C) ADM Soft A-
key to move your Address
cursor•do not l A n&LRf— MA
use the return it !Town
key. y State Zip Code
2. System Owner:
Name
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Address(if different from location)
MA
City(rown State Zip Code
06 Z- � 2'%-3
Telephone Number
B. Pumping Record
1. Date of Pumping Date S 2 2. Quantity Pumped: lo
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 conditi n of component pumped:
f'M
6. System Pumped By:
Dave Tiney Mass 1AA95E Mass 1AD31Z
Name Vehicle License mber
Bateson Enterprises, Inc.
Company
7, tion where contents were disposed:
GLS
-- q I -�,Rr -
signatu of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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