Loading...
HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 485 FOREST STREET 7/29/2024 Commonwealth of Massaof-iusetts C ity/Town of g 2024 System Pumping Record Af ? Form 4 Depelltment 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 oacside rear left' righ 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 0 key to move your A dr ss cursor•do not G use the return MA © 1 p tG key. CilylTown Slate Zip Code .4 2. System Owner: C Name nrun Address (if different from location) MA Cityrrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: ll Date y p Gallons 3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank g ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6. System Pumped By: Dave Tiney Mass 1AA95E Mass 1AD Z Name Vehicle I.Icense Numb r Bateson Enterprises, Inc. Company 7. (Qration where contents were disposed: LS (C Signature of Hauler Dale Signature of Receiving Facility(orattach facility receipt) Date 15form4.doc• 11112 System Pumping Record•Page 1 of 1