HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 242 FOSTER STREET 3/29/2024 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4 MP
DEP has provided this form for use by local Boards of Health. Other forms may be used, but tKe
information must be substantially the same as that provided here. Before u this form, check with your
local Board of Health to determine the form they use. The System Pumping I` Lord must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping dale in
accordance with 310 CMR 15.351.
HOUSE: fron back side rear left Ight
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 lab
key to move your Address
cursor•do not ,�� — MA
use the relurn S
key. Cily/Town Slate Zip Code
r�
2. System Owner:
Name IJ
nrtm
Address (if different from location).
MA
City/Town State Zip Code
Telephone Number
• B. Pumping Record
� 3�.&
1. Dale of Pumping 3 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:
6. System Pumped By:
Dave Tiney Mass F5821 �MassiAA9
Name vehicle License umber
Bateson Enterprises, Inc.
Company
7, nio.n where contents were disposed:
Signature of Hauler Dale
Signature of Receiving Facility(or atlach facility receipt) Dale
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