HomeMy WebLinkAboutSeptic - Pump Chamber - Septic Pumping Slip - 287 FOREST STREET 10/30/2023 Commonwealth of Massachusetts
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.
A. Facility Information
Left/Right front of house, Left/ Right rear of house, Left Right side of house, Under t
Important:When
filling out forms 1. System Location_Left/Right side of building, Left/Right front of building, eft/Right rear of building,
on the computer, 6 /'
use only the tab bb key to move your '-Address _ o
cursor-do not Jl�- _ MA {,C
use the return key. City/Town State Zip Code
,n
2. System Owner:
"x
er�
Address (if different from location)
MA
CityfTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ate 2. Quantity Pumped: gallons C2 6 O
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
then (describe): —
_KO fik"
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Ob ry d condition of component pumped:
OW/W
t
6. System Pumped By:
Dave Tiney Mass F 1 A A4 I5 3
Name Vehicle License um er
Bateson Enterprises, Inc. _
Company
7. L ion re contents were disposed:
GL
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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