HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 770 FOREST STREET 1/2/2024 Commonwealth of Massachusetts
' City/Town of _
System Pumping Record
Form 4 ,pN
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: f�nt
back side rear left right
A. Facility Information BUILDING: back side rear a right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab �V
key to move your Addresp t —
cursor-do not
use the return MA
key. Gty/Town State
Zip Code
2. S stem Owner:
rd
� ;AA
Gl'—
Name IV
rerun
Address (if different from location).
MA
City/Town State i 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 co dition of component pu ped:
�6
6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA95E
Name Vehicle License Nu ber
Bateson Enterprises, Inc.
Company
7. (ETtion where contents were disposed:
LS
Signature of Hauler Dal;
Signature of Receiving Facility(or attach facility receipt) Date
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