HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 326 FOREST STREET 11/2/2021 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.
A. Facility Information
1. System Locationig front off Left/Right rear of housa, Left/right side of house, Left/
Right side of buiMpgrleft/ n of building, Left/Right rear of building, Under deck
Address =� `4;7
Cilylrown State Zo Coda
2. System Owner. '
Name'
Address(if different from locatlon)
Citylrown Stat / 7 ���`� Zip n
Telephone Number `T_
.B. Pumping Record
1. Date of Pumping Date �( 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System P mpe�:
F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where content&were disposed:
O�L S Waste,Water
Sign e b Date
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