HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 326 FOREST STREET 10/7/2022 Commonwealth of Massachusetts
u City/Town of
System P
y Pumping Record o
Form 4 o�EaN of
DEP has provided this form for use by local Boards of Health. Other forrnOs ZN
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: ron ack side reaK__�_"right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Locati n:
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return �Wlly
n/
key. City/flown � State
Zip Code
2. System Owner, d/1
Name X
ieruin
Address(if different from location)
City/Town
Stag i Code
Telephone Number
B. Pumping Record /
1. Date of Pumping
Date 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) ptic Tank ❑ Tank Tight 9 ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present?0 Yes ❑ No If yes, was it cleaned?
Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company —
7. Location where contents were disposed.
GLSD
Signature f Hauler
Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11112
System Pumping Record •Page 1 of 1