HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 458 FOSTER STREET 3/10/2023 aec'�
'Lx Commonwealth of Massachusetts
City/Town of 3
_ �aR l p 1oti ON
System Pumping Record ��pccN�ME01
Form 4 Cv' �EPP
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: <fr back side rear i ht
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Loc
on the computer, 7`_/�-45;'
use only the tab
key to move your --
cursor-do not
use the return City/Town
key. State Zip Code
4:1
2. Sys m Owner:
a
Name
rcrwn r
Address(if different from location)
City/Town Stat
� Zip
�j�e
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2 QuantityPumped:
I, p Gallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4, Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component umped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name
Vehicle License Number
Bateson Enterprises Inc
Company
7. Loc ere contents were disposed:
LS
Signature of Haul
Date —
Signature of Receiving Facility(or attach facility receipt) Date --
t5form4.doc- 11/12
System Pumping Record•Page 1 of 1