HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 600 FOSTER STREET 3/15/2024 Commonwealth of Massachusetts
w City/Town of AR 15 2p24
a System Pumping Record M
Form 4 ;�,�t
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 bac side rear le right
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 6W S S�-
key to move your Addres
cursor-do not
use the return KV 6 MA
key. City/Town Slate Zip Code
2. System Owner:
rd M t�.F f S ,e
Name
nnm
Address (if different from location) .
MA
City/Town State Zip Code
gI �- S`f� - /S s
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: 1 /
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? Q� Yes ❑ No
5. Observed condition of component pumped: /
6. System Pumped By:
Dave Tiney Mass F5821 ass 1AA95
Name Vehicle License Nu er
Bateson Enterprises, Inc.
Company
7. ion where contents were disposed:
GLSD)
off' 2
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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