HomeMy WebLinkAboutSeptic Pumping Slip - 137 Christian Way - 11/5/24 - Septic Pumping Slip - 137 CHRISTIAN WAY 11/5/2024 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. 2ofore 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: ( ront,)back side rearQ Fight
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 Addras
cursor-do not
MA
use the return
key, City/Town State Zip Code
2. System Owner:
Name
Address Qf different from Ipaation)
VIA
State
-Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped, Gallons
3. Component: ❑ Cesspool(s) Septic Tank F7 Tight Tank ❑ Grease Trap
E] Other (describe):
4. Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? M Yes 7 No
5, Observed condition of component pumped:
& System Pyrnped By: �❑
N�alfi❑
1AA95E z
Name
Bateson Enterprises, Inc.
Company
T I= tqn where contents were disposed-,
D
Signature of Hauler Date
_§�gnature_ f Receiving F--.a 'Ii'ty(or h facility
—ci'---a-t-t-a�.c--'f receipt)� Date
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