HomeMy WebLinkAboutSeptic Pumping Slip - 49 Abbott St - 10/29/2024 - Septic Pumping Slip - 49 ABBOTT STREET 10/29/2024 E 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 CIVIR 15.351.
HOUSE:,-"'front�back side rear le right
A. Facility Information BUILDING: fro back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab ve? �1,w,,4 `" 4— —
key to move your Address
cursor-do not MA 61 18` Lf(�-
use the return
key. City/Town State Zip Code
2. System Owner:
�-<-j
Name
Address(if different from location)
MA
Cityfrown State Zip Code
c,(
Telephone Number
B. Pumping Record — 2. Quantity Pumped:1. Date of Pumping -bate' Gallons
3. Component: F-1 Cesspool(s) Septic Tank 7 Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
pw-ol,"i ( _____—
6. System Pumped By:
Dave Tine y Mass 1AA95E ass 1AE3 JAL
Name Vehicle License Number-,
.Bateson Enterprises, inc.
Company
7. Location where contents were disposed:
I GLS r4'
--T4 7,,,�
Signature of Hauler Date
Signature of Receiving,Facility(or attach facility receipt) Date
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