HomeMy WebLinkAboutPumping Slip - Septic Pumping Slip - 140 BRADFORD STREET 12/6/2024 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 1 5.351,
HOUSE: ( back side rear left r 03 <right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, GV
use only the tab --- — (
key to move your "Address -1
cursor-do not MA LA:_
use the return
key. City/Town State Zip Code
2. System Owner:
,p rob
Address(if different from location)
MA
(51�/Town State Zip Code
�qs ----------
Telephone I—ep h-on e N_-u'-m-b er
B. Pumping Record
1, Date of Pumping 2. Quantity Pumped: 4 560
DateGallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
F-1 Other (describe):
4. Effluent Tee Filter present? / Yes ❑ No If yes, was it cleaned? L'A Yes ❑ No
5. Observed condition of component pumped:
MC
6, System Pumped By:
2a�Tiney Mass 1AA95E ass 1 A631 Z
Name Vehicle License Num"Qr ��
Bateson Enter a��es, Inc.
Company
7. 1 n where contents were disposed:
LSD
Signature ofHauler- Date
----------
Signature
of-k-ece-i—vIng-Tacility(or attach facility receipt) Date
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