HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 97 FOREST STREET 12/13/2021 : 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 you
local Board of Health to determine the form they use.The System Pumping Record must be submitted tc
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right ouse, Left/Right rear of house, Left/right side of house, Left
Right side of building,3 Left fight front o building, Left/Right rear of building, Under deck
on the computer, J1 ^��/�
use only the tab / T �"C•/�+C
key to move your Arc Tess
cursor-do not MA Q
use the return key. ity/Town State Zip Code
2. System Owner:
,gVW
Name
rertm `
Address(if different from location)
MA
City/Town State Zip Code
0
Telephone Number
B. Pumping Record
1. Date of Pumping Ila) V 2. Quantity Pumped:
D e El Gallons
3. Component: ❑ Cesspool(s) )k-l-eptic Tank Tight Tank Grea$e Trap
[IOther(describe):
4. Effluent Tee Filter present? ❑ Yes,hSI No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
David Tiney _ Mass F5821 _
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Loca ' where contents were disposed:
LSD Dowell Waste Water
_4 -a1
Signature of Hauler Date