HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 326 FOSTER STREET 8/5/2024 Commonwealth of Massachusetts
h Pad°vet
City/Town of
a System Pumping Record
} t Form 4
DEP has provided this form for use by local Boards of Health, Other forms m used, but the
information must be substantially the same as that provided here. Before usinrs 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 leff' right
A. Facility Information BUILDING: ront back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab }-
key to move your Address
cursor-do not J
use the return 42"�` 6Ue� MA
key.
City/Town State Zip Code
2. System Owner:
iR
� Name ��me
rmm
Address(if different from location)
MA
Cltyrrown State Zip Code
&(')--22`1-1 a
Telephone Number
B. Pufnping Record
1. Date of Pumping —
p 9 Date 2• Quantity Pumped:
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: /
00 cp,--�-
6. System Pumped By:
Dave Tiney _ Mas 1AA95E Mass 1AD31Z
Name Vehic Llcense N mber
Bateson Enterprises, Inc.
Company
7. ation where contents were disposed:
GLS
L
Signature Hauler Date
Signature of Receiving Facility(orattach facility receipt) Date
15form4.doc- 11 112
System Pumping Record P P 9 age 1 of 1