HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 312 FOSTER STREET 5/13/2024 Commonwealth of Massachusetts 3 2024
City/Town of MAC 1
System Pumping Record
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 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 back side rear eft right
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 tab 312 �G✓T�
key to move your Address
cursor-do not !j AGL,-'�— MA j 0 NSA
use the return Citylrown State Zip Code
key.
2. System Owners
Name
"rain
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
CC3
1. Date of Pumping Date b)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 pumped:
Nt5r/^-, 1
6. System Pumped By:
Dave Tiney Mass 1AA95E /114ass 1AD31Z
Name Vehicle License Num er
Bateson Enterprises, Inc.
Company
7. LQretion where contents were disposed:
GLS
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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