HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 485 FOREST STREET 7/21/2023 Commonwealth of Massachusetts
N City/Town of
a System Pumping Record
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, LeftQRightar of house, Left/Right side of house, Under Dec
Important:Whenfilling out forms 1. System ocatio Left/ Right side of building, Left ont of building, Left/Right rear of building,
on the computer, L %5 e,
use only the tab - --- --
key to move your Address
cursor-do not &zoz 'r� — MA
use the return City/T + 1� State - — — Zip Code
key.
2. System Owner:
reb
Address(if different from location)
MA
City/Town Stat Zip Code
93�d-
Telephone Number
B. Pumping Record
1. Date of Pumping IDe Gallons 2. Quantity Pumped: is
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 F5821 A M_5 Q
Name Vehicle License umber
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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