HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 101 COLONIAL AVENUE 10/29/2024 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: rf'r-04 back side rear (ix 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 �(j Ili C-6
key to move your Address
cursor-do not 0 MA
use the return CityfTown State Zip Code
key,
2. Sys7mrwner:
= s; 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 ❑ Tight Tank 7 Grease Trap
r-1 Other(describe):
4. Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? M Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E /,-�Mass 1AD31Z"--",)
Name Vehicle License N,mbar
Bateson Enterprises, Inc.
Company
7. on where contents were disposed:
GLSD
ignature of Hauler Date
Signature of Receiving-Facility(or attach-Fac`irity-receipt) Date
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