HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 50 JOHNNY CAKE STREET 12/15/2025 ( `� Commonwealth of Massachusetts
❑'❑r City/Town of
System Pumping Record
r 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: fron back side rear eft x1ght
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 __-- i_1 ( _.-? _ __ _ _ ----_—__-..____.___
key to move your Address
cursor-do not MA c�
use the return — — .—�_-- --_...__.. ----- — --- -- --- -------�— — ._� _!_.
key.
CityfT'own State Zip Code
` 2. System Owner: ""ff
Name /
Address (if different from location)
MA
City/Fown State Zip Code
felep)one Number
B. Pumping Record _
1. Date of Pumping - / - --- 2. Quantity Pumped: ---� ----
Date Gallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank [] Grease Trap
❑ Other (describe): --— --_ �..`__.___----_-.--- —_—___---.------�._____—__----------____--
4, Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condition of co ponent pumped:
G. System Pumped By:
Dave7lney --'1/1 as s 1AA95E Mass 1AD31Z_ _
Name Vehicle Licens umber — —
Bateson Enterprises, Inc.
Company
T n where contents were disposed:
GLSD
Sign lure Hauler Date —
Signature of Rece=,0 g�Facility(or attach facility receipt) Date — -- --
t5form4.doc• 11/12 System Pumping Record Page 1 of 1