HomeMy WebLinkAboutSeptic Pumping Slip - 25 Jerad - 11/5/24 - Septic Pumping Slip - 25 JERAD PLACE 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 some as that provided here, 9oforo 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 CIVIR 15.351. --------
-------- -------- ------- ......... HOUSE: Qront.,Pack side rear(ej right
A. Facility Information BUILDING: front' back side rear left right
Important:When DECK: under'
filling out forms I System Location.
on the computer,
use only the tab
key to move your Address
cursor-do not MA
use the return
key. city/Town State Zip Code
2. System Owner:
.............. --------- ------
Name
-------------
Address (if different frori location)
-MA
State Zip Code
Telephone-Number,
B. Pumping Record
'i. Date of Pumping 2. Quantity Pumped,
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank Tight Tank ❑ Grease Trap
0 Other (describe): --------- ----------------
4, Effluent Tee Filter present? F-1 Yes No If yes, was it cleaned? El Yes ❑ No
5. Observed condition of component pumped:
6, System Pumped By,
Dave Tlney 31 Z Mass 1 A D
Narne Vehic,I e Lice 1"
—SQ— or
Bateson Enterprises, Inc_ ......
COMP211y
7, Cn where contents were disposed:
SU
.......... --------------
Signature of Hauler Date
Signature of Receiving -acility(or attach facility receipt) Date
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