HomeMy WebLinkAboutSeptic Pumping Slip - 150 Christian Way - 10/25/24 - Septic Pumping Slip - 150 CHRISTIAN WAY 10/25/2024 Commonwealth of Massachusetts
City/Town of
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 16.351.
—-----------------HOUSE. (�r�on Iack side rear(t_,_ft right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location,:
on the computer,
use only the tab
key to move your Address
cursor-do not MA is
use the return
key. City/Town State Zip Code
2. System Owner:
Name
reran
Address(if different from location)
MA
CityfTown State Zip Code
CP c
Telephone Number
B. Pumping Record
1. Date of Pumping -bate 2. Quantity Pumped: Gallons
3. Component: 7 Cesspool(s) Septic Tank 7 Tight Tank 7 Grease Trap
F1 Other(describe): ---------
4. Effluent Tee Filter present? D Yes No If yes, was it cleaned? M Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Mass IAA95E lvass'IAD3�Z)
Name Vehicle License
Bateson Enterprises,
Company
7. tion where contents were disposed:
GLS
T2
Signature of Hauler Date
-Signature of Receiving Facility(or attach—facility'-receipt) Date t5form4.doc-11112 System Pumping Record-Page 1 of 1