HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 98 FOREST STREET 10/2/2023 Commonwealth of Massachusetts
H City/Town of O�tip'1
a System Pumping Record oC�
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/R ht rear of house, Left/ Right side of house, Under Dec
Important:When
filling out forms 1. Sy tem Loc tion: Left/Right side of building, Le Right front of building, Left/Right rear of building,
on the computer,
use only the tab -
key to move your kAil dress cursor-do not 01 MA
use the return /Town - State Zip Code
key.
2. System Owner
Name
_--
Address(if different from location)
MA
City/Town State � r Wde
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 condition of component pumped:
6. System Pumped By:
Dave Tiney _ Mass F58 A 4
Name Vehicle Lice se umber
Bateson Enterprises, Inc.
Company __
7. Location where content were disposed.
G LSD - - - --
Signature of er Date
Signature of Receiving Facility(or attach facility receipt) Date
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