HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 571 FOREST STREET 3/15/2024 Commonwealth of Massachusetts �P; {
City/Town
rt Prom in Record MPR15 �p2�
R Y � 9
a
Form 4
�Y
DEP has provided this form for use by local Boards of Health. Other forms YVP,&p e47,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: ron back side rear left right
A. Facility Information auitolN�: nt back side rear le right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, -}IUD use only the lab 5 s
key to move your Address I
cursor•do not N An CaU�,, MAr r G
use the return key. City/Town State Zip Code S
r�
2. System Owner:
Co lle' Scn
Name
rvnrn
Address(it different from location) .
MA
City/Town State Zip Code
3 31 •ZZy -05-S ti
Telephone Number
B. Pumping Record
1. Date of Pumping Date f( IZy 2 Quantity Pumped: Gallons�6
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. ObserveeAd'� conditio�t of component p roped:
6. System Pumped By.-
Dave Tiney _ Mass F5821 ss 1AA95
Name Vehicle License Num r
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
GLSD
Signature of Hauler Dale A/Z y
Signature of Receiving Facility(or attach facility receipt) Date
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