HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 340 FOREST STREET 12/4/2023 Commonwealth of Massachusetts
H City/Town of
System Pumping
p g Record p
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.
ront ack side
A. Facility Information BUILLDING: font back side rear le�ri
t
Important:When
filling out forms 1. System Location: DECK: under
on the computer, 3 & l— Y�
use only the tab
key to move your Addr s
cursor- not
use the return
urn
key. CitylTown MA
State Zip Code
� 2. System Owner:
il�
Name T
Cl
rerun
Address Of different from location).
City/I own MA
State Zip Co e
Telephone B. Pumping Record Number
1. Date of Pumping /(I Z Z�
Date 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank
❑ Tight Tank El Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? Yes No
Yes ❑ No If yes, was it cleaned?
❑
5. Observed condition of component pumped:
lu0�'Mti
6. System Pumped By:
Dave Tiney Mass F5821 Name Mass 1AA95E
Bateson Enterprises, Inc. Vehicle License Nu er
Company
7 tion where contents were disposed:
GLSD
-?
Signature of Hauler Z
Date
Signature of Receiving Facility(or attach facility receipt) Date
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