HomeMy WebLinkAboutSeptic Pumping Slip - 30 Summer - Septic Pumping Slip - 30 SUMMER STREET 10/4/2024 Commonwealth of Massachusetts
PERE
City/Town of
y System Pumping Record
:? Form 4
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 back side rea left right
A. Facility Information BUILDING: frutit back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, C
use only the tab
key to move your Address
cursor-do not MA
use the return City(rown State Zip Code
key.
2. System Owner:
�•.mac. `��`-.3r\
ZIAName'
Address(if different from location)
MA
Cityrrown State Zip Code
01 t
7elephone Number
B. Pumping Record
1. Date of Pumping lU 2. Quantity Pumped:
pate Gallons
3. Component: ❑ Cesspool(s) Septic Wank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4, Effluent Tee Filter present? ❑ Yes No If yes, was It cleaned? ❑ Yes ❑ Igo
5. Observed condition of corn anent pumped:
1�U(Mc.
6. System Pumped By:
Dave Tiney Mass 1AA956 Mass 1AD
Name Vehicle License Num er
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
VLSDD --
�" fu 2 y
Signature of Hauler Date M
Signature of Recelving i"acility(or attach facility receipt) pate
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