HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 165 FOREST STREET 4/17/2024 Commonwealth of Massa'dhusetts
City/Town of APR 17 2024
System Pumping Record
Form 4 tt y� y 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: ®ront
ack side rear le right
A.,Facllfty Information BUILDING: back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, �
use only the lab G
key to move your Add ess
cursor• not J s ���JQ� MA ��g
use the return
urn key. Cily/Town Stale Zip Code
2. Stem Owner: _
Name
nrtm
Address (if different from location).
MA
Cityrrown Slate lip Code
cot
Telephone Number
B. Pumping Record
1. Dale of Pumping �3 h'v 2. Quantity Pumped: /
Oate 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 p roped:
D6 rM�t l
6. System Pumped By:
Dave Tiney Mass F5821 �1AA95E
Name Vehicle LicenseQumber
Bateson Enterprises, Inc.
Company
7. where contents were disposed:
G�ion
2
Signature of Hauler Dale
Signature of Receiving Facility(or attach facility receipt) Date
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