HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 326 FOREST STREET 9/21/2023 Commonwealth of Massachusetts
u City/Town of
F System Pumping Record g�@
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.
HOUSE; ront ck side rear left right
A. Facility Information BUILDING: front back side rear right
Important:When DECK: under
filling out forms 1. System Locati
on the computer,
use only the tab
key to move your A dress
cursor-do not MA
use the return City/Town
key. State Zip Code
2. S tem Owner:
Otb r
Name
nam
Address (if different from location)
MA
City/Town Stat `// Code
Le 9 27 a �z
Telephone Number
B. Pumping Record 3 1 Date of Pumping ate 2. Quantity Pumped: Gallons
3 Component ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter prese Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By: - --
Dave Tiney Mass F5821 ass Z95E
Name Vehicle License Numb
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
GLSD
Signature auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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