HomeMy WebLinkAboutSeptic Pumping Slip - 163 Summer 9.11.2024 - Septic Pumping Slip - 163 SUMMER STREET 9/11/2024 Commonwealth of Massacriusetts
u City/Town of
System Pumping Record
3
>' Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, btli 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 submi"ed to
the local Board of Health or other approving authority within-!4 days from the pumping date in
accordance with 310 CMR 15.351
HOUSE: front b a cil side rear le� right,
A. Facility Information BUILDING Iron; ack sine rear left right
Important:When DECK: under
ailing out forms 1. System Location:
on the computer,
use only the tab
key Io move your Address
cursor e do not _ MA
use the return _
key. Cilyl own State Zip Code
2. System Over
411:1
Xt
Name4
LIZ
Address (if different from iocation,
MA
CIIy.Town -- Slate zlp Code ——
_ Telephone Number
B. Pumping Record
1. Date of Pumping Ca1e 2. Quantity Pumped
Gallons
3. Component ❑ Cesspool(sj Septic Tank ❑ Tight Tank n
f i Grease Trap
❑ Other (describe): —
4. Effluent Tee filter present? ❑ Yes 'No if yes, was it cleaned? ❑ Yes [ No
S. Observed condition of component pumped
6 System Pumped By _
Dave Tiney Mass 1AA95E Mass 1AD31Z
Name Vehicle License N mber
Bateson Enterprises, Inc.
Company
7, CGLSDwhereo contents were disposed
41 'r_h
Signature of Hauler Date
Signature of Receiving FaeiIi ky (or-aO.ach facility receipt} Date
151orm4.doc 11112
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