HomeMy WebLinkAboutSeptic Pumping Slip - 50 Johnny Cake St - 11/21/2024 - Septic Pumping Slip - 50 JOHNNY CAKE STREET 11/21/2024 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. 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 side rear C6fb right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
fllllng out forms 1. System Location:
on the computer, , ,
use only the tab fr c"N
key to move your Are s
cursor-do not MA LIS:
use the return
key, City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
/2
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: 7 Cesspool(s) Septic Tank M Tight Tank F1 Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? Yes E] No If yes, was it cleaned? Yes 7 No
5. Observed condition of component pumped:
6. System Ppmped By:
Dave Tiney Mass 1AA95E (""'Mass I AD31Z",-.,
Name Vehicle License Numbef
Bateson Enterprises, Inc.
Company
T 6-"c�'on where contents were disposed:
0
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc-11112 System Pumping Record Page 1 of 1
