HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 990 FOREST STREET 5/20/2022 Commonwealth of Massachusetts VjFCFj\JaU
_ City/Town of
System Pumping Record MAY 202022
TOWN OF NO
r RTHT
Form 4 N00VEH MENT
TH pEPAR
DEP has provided this form for use by local Boards of Health. Other forms r a 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.
A. Facility Information
Left/Right front of house, Left/R► ar of house, Left/Right side of house, Under Deck
Important:When
filling out forms 1. Sy tern Locati n: Left/Right side of building, Left/ i ht front o uilding, Left/Right rear of building,
on the computer, JQA e
use only the tab I h
key to move your Add ss
cursor-do not .y4n��(�e'� MA �y
use the return key. ity/Town State Zip Code
2. Sys Owner:.
� ,
Name
Address(if different from location)
_ MA
-City/--row. State Zip Code
Telephone Number
B. Pumping Record
2
1. Date of Pumping Date 2. Quantity Pumped: 64
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): - -- - ------ --
4. Effluent Tee Filter present? ❑ Yes A
No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Loc where contents were disposed:
�LSD
14
- -
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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