HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 312 FOSTER STREET 7/3/2023 7
Commonwealth of Massachusetts
City/Town of �-�
System Pumping Record w` pg2W3
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 yo
local Board of Health to determine the form they use. The System Pumping.Record must be submitted
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 back side rear left righ
A. Facility Information BUILDING: front back side rear left righ
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, 92 �
use only the lab
key to move your ress
cursor•do not
use the return
key. City/Town State Zip Code
2. System Owner:
Name
inwn '
Address (if different from location)
City/Town . State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: /sue
Gallons
3. Component: ❑ Cesspool(s) Septic 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 pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. (� Cion where contents were disposed.
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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