HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 122 FOSTER STREET 8/23/2023 Commonwealth of Massachusetts
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City/Town of
System Pumping Record
Form 4
M
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 baci side ear left right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Locatio�j
on the computer,use only the tab )22— y 1
� -------- -
key to move your Address
cursor-do not MA {
use the return —to -- —
key.
Cit own State Zip Code
2. System Owner:
Name
rerun
Address(if different fr location)
MA
City/Town State Zip Code
- _r_3 - �s
Telephone Number
B. Pumping Record c
1. Date of Pumping o I 2. Quantity Pumped.
Date 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 componen pumped:
6. System Pumped By:
Dave Tiney Mas F5821 Mass 1AA95E
Name Vehicl Licens umber
Bateson Enterprises, Inc. —
Company
7. Lqaajion where contents were disposed:
LSD
Signature�Hau Date
Signature of Receiving Facility(or attach facility receipt) Date
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