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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 769 FOREST STREET 11/21/2023 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 NQV 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 bac side rear left ight A. Facility Information BUILDING: front back side rear left right Important:When DECK: under filling out forms 1. System Location: on the computer, use only the tab p key to move your Address cursor- not © �y� use the return urn Ci//�``N own ` MA � key. y State Zip Code VQ 2. System Owner: M Ae-to- 115-Y1 Name rerun Address (if different from location) _ __ City/Town MAState nI 1 c �^u ZMip,Code _ Telephone Number B. Pumping Record 1. Date of Pumping Date Z 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 conditio of component pumped: o r&,c, 6. System Pumped By: Dave Tiney Mass F5821 Mass 1AA95E Name Vehicle en umber Bateson Enterprises, Inc. Company 7 0, tion where contents were disposed: GLS Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1