HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 230 FOREST STREET 12/4/2023 Commonwealth of Massachusetts
H 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: fron back side rear le rig
A. Facility Information BUILDING: rout back side rear left
Important:When
DECK: under
filling out forms 1. System Location:
on the computer, � �-5
use only the tab
key to move your Addres 1
cursor-donot ') / Cb` MA
use the return
urn Cit /Town
key. y State Zip Code
2. S stem Owner. l
PS ►"'' � le.f
Name
rerun
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping (�3 2. Quantity Pumped: ,�6
Date 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:
IU6^I`^yI
6. System Pumped By:
Dave Tiney Mass F5821 M ss 1AA95E
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7, tion where contents were disposed:
GLSD
--
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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