HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 135 FOSTER STREET 7/17/2023 QP�
1C_\ Commonwealth of Massachusetts
City/Town of
System Pumping Record
w
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.
A. Facility Information
Left/Right front of house, Left Right r ar of house, Left/Right side of house, Under C
Important:When
filling out forms 1. System Location: Left/Right side of building, Left/kNttffront of building, Left/Right rear of building,
on the computer, Ix
use only the tab
key to move your Address
cursor-do not ti bh\A�� MA
use the return CityrTown State Zip Code
key.
2. System Owner:
E/,-A-a cN5
Name
ietum
Address (if different from location)
MA
CityrTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping pate �3 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 condition of component pumped:
u6 �",
6. System Pumped By:
Dave Tiney Mass F582 14�,A,49
Name Vehicle License tuber
Bateson Enterprises, Inc.
Company
7. n where contents were disposed:
GLSD
11
\1___1 oRr ____ - - --- — -:� L b
Signature o auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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