HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 12 FARNUM STREET 12/4/2023 Commonwealth of Massachusetts
w City/Town of
System Pumping Record ,�� �®
GSM V,`p
Form 4 N ��
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 side rear left fight
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 �-
key to move your Address
cursor- not p An %l use the return
Iy Curn MA
key. City/Town State
Zip Code
re
2. System Owner:
�C�nn
Name
anm
Address (if different from location) .
_ MA
Cityrrown State Zip Code
40* Cl"?-�--
Telephone Number
B. Pumping Record
1. Date of Pumping Date — 2. Quantity Pumped: y�b6
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 pu ped:
IE.hr �
6. System Pumped By:
Dave Tiney Mass F5821 ass 1AA95E
Name
Vehicle License Nu er
Bateson Enterprises Inc.
Company
7. tion where contents were disposed:
GLS
Signature of Hauler Date
Signature of Receiving Facility(or attach facilityt recei P) Date
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