HomeMy WebLinkAboutSeptic Pumping Slip - 100 Johnny Cake St -11/20/2024 - Septic Pumping Slip - 100 JOHNNY CAKE STREET 11/20/2024 Commonwealth of Massachusetts - )
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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 esmo as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The Sye0arn 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 31OCK0R15.351. -
A. Facility Unfm`r00at-oKl BUILDING: front back side rear left right
DECK: under
Important:When '
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your *duress |
cursor'uonot MA
use the return
hay. City/Town State ~,~,.,
2. System Ow
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1, Ooha of Pumping 2Date � Quantity Pumped:
Gallons
3. Component: Cesspool(s) Septic Tank 7 Tight Tank F1 Grease Trap
[] Other (describe):
4. Effluent Tee Filter present? 7 Yes No |f yes, was itcleaned? Yes Fl No
5. Observed condition of component pumped:
6. SystemPumped B
yy:
Oe»eT|n Mass 1A\95E
Name Vehicle License
Bateson Enterprises, Inc.
Company
7. disposed:
-§ignature of Hauler D@LV
Signature of Receiving,Facility(or attach facility re-c�lpt) Date
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