HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 64 FOREST STREET 5/31/2022 RECEIVED
�L\ Commonwealth of Massachusetts
N City/Town of Mpy 312022
a System Pumping Record YHAt[)0\JF
f NO
, N
Form 4 'fOH&-TVAt,)F-IP 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. 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: ro7n3 back side rear(Z)right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, j i/
use only the tab "`�
key to move your Address
cursor-do not ib• b��
use the return City/Town State Zip Code
key.
2. System Owner:
dab
Name
ierwn
Address(if different from location)
City/Town State Zip Code
a -79 g6iP 3dic)
Telephone Number
B. Pumping Record
1. Date of Pumping L C' 1 2. Quantity Pumped: I �00
Date Gailons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): ---- -- ----
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? s ❑ No
5. Observed condition of component pumped: l(111
6. System Pumped By:
Dave Tiney _ Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Signature of Hauler D-A
Signature of Receiving Facility(or attach facility receipt) Date
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