HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 536 FOREST STREET 4/29/2024 Commonwealth of Massachusetts
Gity/i own of ��°
V y �J b'4r •i
Form 4
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 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 Inforrnat' . -- - --- _
Le Right fro t of house,. Left/Right rear-of house, Left/Right side of house, Under C
Important:When
filling out forms 1. System Location. Left/ Rig t side of building, Left/Right front of building, Left/Right rear of building, .
on the computer, 4!:3
S�
use only the tab — --
key to move your Addre s
cursor-do not MA
use the return - — __ -- ---.-- ---.___.
key. ity/Town State Zip Code
2 S stem wrier:
Nam
HIM
Address(if different from location)
MA
�ity/Town _ Slala 7.ip Carle
Telephone Number
B. Pumping Record
1 Date of Pumping �+Septic
2. Quantity Pumped: ---
ate Gallons
3. Component: ❑ Cesspool(s) Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If ves, was it cleaned? I1 Yes n No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tine _ Mass F5821 �t44 9_5ie
Name Vehicle License umber T.
Bateson Enterprises, Inc.
Company
7. Locatio -,Ja-r e contents were disposed:
71
Signature of Hauler Date
Sign afuie of RN[:Niviiiy Fatality(i)i attai;i-1 fat:iiiry rui:i:i{,i i n ai.p.
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