HomeMy WebLinkAboutSeptic Pumping Slip - Septic Pumping Slip - 767 JOHNSON STREET 10/17/2024 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DE✓P 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 hore. Before using this form, oheok 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('s q :rear (eF right
A. Facility Information BUILDING: front back side rear left right
Important;When DECK: under
VIling out forms 1. System Location:
on the computer, r
use only the tab ✓'
key to move your Ad rdss -
cursor-do not ) d; _ MA
use key,
return y, Cltyrrown State Zip Code
2. System Owner:
Name
rruvn y.'`
Address(If 83fferent from location) —
_MA
Cltyi7own State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping oaten -- 2. Quantity Pumped: .
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): —
4. Effluent Tee Filter present? ❑ Yes ( No 1f yes, was it cleaned? ❑ Yes ❑ No
5. Observed cord•ition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA96 Mass 4AD31Z.?
Name Vehicle License Number,.,...._�__.._
Bateson Enterprises, Inc.
Company
7. L cat..on where contents were disposed:
GLSD)
Signature of Hauler (date
Signature of Receiving Facillty(or attach faciilty receipt) Date
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