HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 458 FOSTER STREET 3/15/2024 Commonwealth of Massachusetts
City/Town of
a System Pumping Record
a
-Form 4 erk
DEP has provided this form for use by local Boards of Health. Othe` �� used, but the
information must be substantially the same as that provided here.�$ a 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 ack side rear le �righ
A. Facility Information BUILDING: r back side rear left right
Important:When DECK: under
filling out forms 1. System Locatio
on the computer, (�
use only the lab fps J�-
key to move your Address
cursor- not L� �6 MA t�{%
use the retet urn
key. Cily/Town State Zip Code
f ve
2. Sy�r�Owner.
r)
Name J
nnm
Address (if different from location) .
MA
City/Town State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping D 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 condition of component pu ped:
rr,s�
6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA95
Name Vehicle License Nu ber
Bateson Enterprises, Inc.
Company
7. ation where contents were disposed:
GLS
tti I2y
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
15form4.doc- 11/12
System Pumping Record•Page 1 of 1