HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 FOSTER STREET 4/25/2023 RECEIVED
<L. Commonwealth of Massachusetts
City/Town of APR 2 5L023
a TOWN
System Pumping Record
HEALTH DEPARTMENTDEPARTMENTJT
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 ba ii
d rear left
A. Facility Information BUILDING: front back a rear left right
DECK: under
Important:When
filling out forms 1. System Lo tion:
on the computer,
use only the tab _
key to move your s
cursor•do not -A )26 a, 6�bax6a
key.
use the return C y/Town - ' State Zip Code
2. Sys em Owner:
rrA
Pam&A�n�S
N me
mwn
Address(if different from location)
City/Town State /_Z �^ ,/Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): -- - -
4. Effluent Tee Filter present?6zes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pum ed:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L ation her contents were disposed:
IS
Signature of Hauler Date
—3
Signature of Receiving Figity(or attach facility receipt) Date
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