HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 98 FOREST STREET 12/5/2022 t�ECE1VED
�\ Commonwealth of Massachusetts
City/Town of _ 052022
System Pumping Record �Ec vER
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351. -
HOUSE: front Qside® left right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Locatio
41
on the computer, G � S
use only the tab _1
key to move your Address
cursor-do not
Ay,use the return
�c'� 4
key.
City/Town Slate Zip Code
2. System Owner:
rab
K n r �e
Name
(�
rrmm • - lz— bces4
Address (if different from location)
City/Town State Zip Code
S_ 7c�k
Telephone Number
B. Pumping Record
1. Date of Pumping Date 11Z� 2. Quantity Pumped: K�
Gallons
3. Component: ❑ Cesspool(s) ld Septic Tank ❑ Tight Tank
g El Grease Trap
❑ Other (describe): ----
4. Effluent Tee Filter present? ❑ Yes ] No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed conditiT
of component pumped:
l��rMk
6. System Pumped By.-
Dave Tiney Mass 1AA95E
Name vehicle License Number -
Bateson Enterprises Inc
Company
7. Lo tion where contents were disposed:
GLSD
Sig ature f auler Date Z
Signature of Receiving Facility(or attach facility receipt) Date
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