HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 329 REA STREET 12/3/2024 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
lEP has provided this form for use by local Boards of Health, Other forms may be used, but the
information must be substantially the same is 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 -he pumping date in
accordance with 310 CMR 15,351
HOUSE: Lfr 0_2t >a c k side rear Cle� right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: undpr
filling out forms I S stem Location:
on the computer, T
use only the iab
A
key to move your
cursor-do no(
1_ - 12 _�
use the return 'lyfT
key, State
4 Zip Code
2. System 0wr r,
4411-ZI
" 4?
Z
- ----1me
1X III1L A�_d-re-s s (-I f ro-d-i_ff-e-u)(-from-- -
MA
State
C i_t;/Folw Code7
Telephone Number
B. Pumping Record
1. Date of Pumping2 Quantity Pumped� _G Mons—
3, Component: F-3 Cesspool(s) 61���ep't i c Ta n k Tight Tank ❑ Grease Trap
❑ Other (describe): -------
4, Effluent Tee Filter present? E] Yes 4-No If yes, was it cleaned? El Yes [] No
5. Observed condition of component pumped:
6, System Pu,n-iped By
(Dave Finey Mass IAA95E Mass 1AD31Z
----------
Narne Vehicle License Number
82ieson Enterprises, Inc,
Company
7. Location where contents were disposed:
G 1_5 D
Signature of Hauler Date
Signature of Receiving Faci acuity (or attach facility receip�) Datr,
t5form4.doc- 11112 System Pumping Record - Page 1 of 1