HomeMy WebLinkAboutSeptic Pumping Slip - 171 Liberty St - 11/26/2024 - Septic Pumping Slip - 171 LIBERTY STREET 11/26/2024 Commonwealth of Massachusetts
City/Town of
0 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:( �fronb� ack side rear left right
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 I I ( L4,4
key to move your Ad6ss
cursor-do not ,A r\ MA
use the return City/Town State Zip Code
key.
2. System Owner:rab �0 5q2�,
Name
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: 7 Cesspool(s) Septic Tank F7 Tight Tank ❑ Grease Trap
F-1 Other (describe):
4. Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tlne y Mass 1AA95E ,---mass iAkb�
Name Vehicle License Number
Bateson Enterprises, Inc.._____
Company
7. Le on where contents were disposed:
LSD
Signature of Hauler Udiv
Signature of Receiving Facility—(or attach—facility-re—ceip—t) Date
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