HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 64 FOREST STREET 10/24/2023 L�,\ Commonwealth of Massachusetts
City/Town of 1>�
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.
HOUSE: front back 4Drear (Tyight
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Locatiop:
�L on the computer,
use only the lab !
key to move your
Ni �A ress
cursor•do not _ _ _ _ MA al kc=ls____
use the return Cityrrown Stale Zip Code
key.
2. System Owner:
---
Name
Address (if different from location)
_ MA
City/Town State .Zip Code
Telephone Number
B. Pumping Record
2 ____
1. Date of Pumping Date/v 6 2. Quantity Pumped: Gallons
i
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): ----- —
4. Effluent Tee Filter present? r Yes ❑ No If yes, was it cleaned? Q� Yes ❑ No
5. Observed condition of component pumped: r
6. System Pumped By.
Dave Tiney _ Ma F582 Mass 1AA95E —
Name Vehi e License mber
Bateson Enterprises, Inc. _
Company
i
! 7. tion where contents were disposed:
1
' �'K - - I Y_
Signature of Hauler Date
1 Signature of Receiving Facility(or attach facility receipt) Date
i
i t5form4.doa 11/12 System Pumping Record -Page 1 of 1
I