HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 675 FOSTER STREET 4/29/2024 o
Commonwealth of Massachusetts -
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Form 4
DEP has provided this form for use by local Boards of Health. &thier 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,
A. Facility Information
Left/Right front of house,. Left�ighttr•-of house, Left/Right side of house, Under C
Important:Whenf r 1. S stem ocati • Le /Right side of building, Leftnt of building, Left/Right rear of building, .
filling out forms � �y
on the computer, Juse only the tabA—� -- -
key to move your Ad ress
cursor-do not T�L� MAuse the return — — -- -- — —---- ----
key. cltyrrown State Zip Code
2 Stem Owner:
Name
rerwn
Address(if different from location)
MA
Stala `7r
Telephone Number
B. Pumping Record
1 Date of Pumping 6ate -- - 2. Quantity Pumped: Gallons -- --
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): --- --- -- ------
4. Effluent Tee Filter present? ❑ Ye No If yes, was it cleaned? ❑ Yes ❑ No.
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass F5821 A,4 9j,�j•
Name Vehicle License u mber
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
G
v
Signature of Hauler Date
Signature of R�i:Hiviiiy r ACalliy(ii atl'di:il fei:illty risi:ial)ij flake
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