HomeMy WebLinkAboutSeptc Pumping Slip - 337 Summer - 11/1/24 - Septic Pumping Slip - 337 SUMMER STREET 11/1/2024 Commonwealth of Massachusetts
City/Town of
.0 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 trust be substantially the sorro os that provided hero. Before using this form, chock 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: fro Rb back side rear("eA right
A. Facility Information BUILDING: front back side rear left right
Important; When DECK: under
filling out forms 1. System Location,
on the computer, 33'�--
use only the tab
key to move your Address
cursor-do note MA
use the return
key, City[Town State Zip Code
2. System Owner:
Name
Address (If different from location)
X1
MA CltyfTown n State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped.
3. Component: F7 Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
F-] Other (describe). —-----
4. Effluent Tee Filter present? E Yes No If yes, was it cleaned? ❑ Yes [] No
5, Observed condition of component pumped:
6. System Pumped By:
D ve TI Mass 1AA95E ass 'lAD31Z
Name Vehicle License Numb
Bateson Enterprises, Inc.
("ornpany
7, Lp"Ition where contents were disposed:
LSD
............... ------..............
Signature of Hauler Date
Signature f Receiving ilty(or attach facility receipt) Date
- Fac',J
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