HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 357 REA STREET 4/13/2026 _ Commonwealth of Massachusetts own orb n oVe
- _ setts r
-- City/Town of
APR 17 2026
System Pumping Record
Form 4
ent
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. 9Pfore 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 0 M R 15.351
-- HOUSE: front back side 'ear left ir,ht
-.---
A. Facility InformationBU1LDlNG: front back sl e rear Ift right
Important: When DECK: under
filling out forms 1. System tIOC
on the computer, 'y�"ti:, tr OIL
^'
use only the tab
key to move your Addr�qs __._.cursor-do notMA
use the return —_ ____._Clly n - __ _...._ ____..
key, tale Zip Code
2. System 0wr,er:
- _ --- - -- =-= '
_ --- ----- -Name
__._.----_.---
r ,
Address (it different from location) --------
ly/Town ---- ---._.
MA
Cl
State
_ ___
--
ip Code
-- _ - - --- - -- -------
Telephone Number
B. Pumping Record
_ _
1. Date of Pumping r3-te___.___ ._-- _ 7 Quantity Pumped
Gallons
3, Component'. ❑ Cesspool(s) ,. Septic 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 componenXp ,�ned,
76. stern fum ed By
Dave T i n —`------..._---_-_--_.---._____ ----..----_-_-__ Mass 1 AA 9 5 E ass 1 A D 3'1 Z
Name Vehicle License Number
Bateso nterprises, Inc.
Cornp y
7. k cation wh contents were disposed
LS
-S - of- --p
.__._ _.n r - - ) _.
Signatr�ire of Receiving Facility (or attach facility (eceipt) Date
15form4.doc, 11112 Systern Pumping Record page 1 of 1