HomeMy WebLinkAboutSeptic Pumping Slip - 10 Liberty - Septic Pumping Slip - 10 LIBERTY STREET 10/7/2024 C
Commonwealth of Massachusetts
r City[Town of
a System Pumping Record
:? Form 4
DIP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the some 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 CMi2 16,361. ry
MOUSE: front bac side �rearght
A. Facility information BUILDING: front back si a
Important,When
BECK: under
tilling out forms 1. System f.oeati n:
on the computer,use only the tab t+
U Lr
key to move your Address
cursor-do not �d MA
use the return
key. Clty/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
_ MA
Cltyrrown State Zip Code
r Telephone Number
z
B. Pumping Record
1. Date of Pumping lof 41' 2. Quantity Pumped:
-bate Gallons
r
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 condition of component pumped:
6. System Pumped By:
Dave Tlney Mass 1AA95 Mass 1ADVZ
Name 1lehlcle License umber
Bateson Enterprises, Inc.
Company T
7. eat'on where contents were disposed:
GLSD
1O h-
Sig nature of Hauler Date
Signature of Receiving Facility(or attach facility reaelpt) Date
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