HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 193 FOSTER STREET 7/17/2023 �LN Commonwealth of Massachusetts
N City/Town of PP
System Pumping Record
Form 4 N
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.
A. Facility Information ---- -
Left/ Right front of house, Left/ Right rear of house, Left Rig side of house, Under C
Important:When
filling out forms 1. System Location: Left/ Right side of building, Left/ Right front of building, Left/Right rear of building,
on the computer, �O l
use only the tab �S -- --- —-- ----
key to move your Address C'��lJ� — — -
cursor-do not /►��(� ,n MA
use the return Cit (Town State Zip Code
key. y
2. System Owner:
ray
5c'G ' s -
Name
a Address(if different from location)
MA
City(Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: 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 condi ion of component pumped:
6. System Pumped By
Dave Tinel y Mass F5821 µa A4 975
Name Vehicle License umber
Bateson Enterprises, Inc.
Company
7. L on where contents were disposed:
L
SD
Signatu o Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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