HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 125 GRAY STREET 12/12/2024 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 CMR 15.351 .......
HOUSE: , front back side rear left<�a
A. Facility Infor--m--ation BUILDING:��ront 'back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab C;4
key to move your Address
cursor-do not MA (S
use the return —1j. C�-V--
key. CityfTown State Zip Code
2, Sy eem Owner:
Name
few 4
Address(if different from location)
MA
CityrTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date /sco
2. Quantity Pumped: Gallons
3. Component: ❑ 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 7 No
5, Observed condition of component pumped:
6, System Pumped By:
_Dave Tines Mass 1AA95E,,-"Mass I AD-m
Name Vehicle License
Bateson Enter rises, Inc.
-E—om—pa-ny-
7. on where contents were disposed:
Ca LS
z dA
Signature of Hauler Date
Signature TpfReoeWngYWc�t�ry(or attach facility receipt) Date
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