HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 370 FOSTER STREET 12/21/2023 Commonwealth of Massachusetts
City/Town of
a System Pumping Record
w Form 4 }�EC �
M '�
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 back side rear left right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, 3`0 To
S�use only the tab -
key to move your Address _
cursor- not N _ ���- Q,���
use the return
urn ^R MA
key. City/Town State —
Zip Code
2. System Owner:
�d \
M Name
nnm
Address (if different from location) .
MA
City/Town State Zip Code
CAI fr Co
Telephone Number
B. Pumping Record
1. Date of Pumping Date S 2 2. Quantity Pumped: �5U6
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank El Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ YesfNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condi ion of component p. ed:
t?t'
6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA95
Name Vehicle License Num r
Bateson Enterprises Inc.
Company --
7(]GLS
tion where contents were disposed
_ ►Z Is jL3
Signature of Hauler Date —
Signature of Receiving Facility(or attach-fa Ii receipt) Date
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