HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 485 FOSTER STREET 8/26/2024 Commonwealth of Massachusetts 1A0111�c
City/Town of
a
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. Befori iAinglhis 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 -he pumping date in
accordance with 310 CMR 15.351.
HOUSE: front Pack
side rea le . right
A. Facility Information BUILDING: front side rear left right
Important:when DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab r fo S
key to move your Address
cursor-do not f�,� ,
use the return K) "`C MA
key. CitylTown State Zip Code
2. Syste Ow er.
rd -1(e-
Lr
Name
Warn
r
Address(if different from location)
MA
City/Town State Zip Code
2(9 -46
Telephone Number
B. Pumping Record
� I S,c
1. Date of Pumping Date 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 conditio of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95 Mass 1A 12
Name Vehicle License umber
Bateson Enterprises, Inc.
Company
7. cation where contents were disposed:
GLS
t t
Signature of Hauler Date
f Receiving Facilit or attach facility receipt) Date
Signature o R t g y( ty p)
15form4.doe- 11/12 System Pumping Record•Page 1 of 1