HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 96 FARNUM STREET 11/27/2023 Commonwealth of Massachusetts
City/Town of
System Pumping Record %
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 a side rear left righ
A. Facility Information BUILDING: front back side rear left right
Important:When DECK:
filling out forms 1. System Location:
on the computer, Of^ �rn uM S 1
use only the tab `-' (p
key to move your Address
cursor-do not � } OU,�
use the return �" MA Q S
key. City/Town State Zip Code
ne
2. System Owner:
I `f^('CJ�c�!e �/1S ton e
Name
wren
Address(if different from location)
MA
City/Town State Zip Code
y35
Telephone Number
B. Pumping Record
1. Date of Pumping Date Its 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:
Not-c-c,
6. System Pumped By:
Dave Tiney Mass F582 Mass 1AA95E
Name Vehicle ' e Number
Bateson Enterprises, Inc.
Company
7. L ion where contents were disposed:
GLS
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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