HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 119 LIBERTY STREET 12/2/2024 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 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 1�(e"
key to move your Address
cursor-do not N , 00�-(� MA
use the return City[Town State Zip Code
key.
2. System Owner:
. --
e
rerun ,
Address(if different from location)
MA
City(Town State ciw Zip Code
-Telephone Number
B. Pumping Record
Ago
1. Date of Pumping Date [2 2. Quantity Pumped: Gallons
3. Component: 7 Cesspool(s) Septic Tank ❑ Tight Tank 7 Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
1z
Dave Tines Mass I AA95E "A�ass 1, L—
Name Vehicle License Nu ber
Bateson Enterprises, Inc.
Z-o—mpi—ny--
7. Lo tion where contents were disposed:
G aLLS§
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Signature of Hauler Date
-Signature of-Receiving'Facility(or attach facilityreceipt) Date
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