HomeMy WebLinkAboutSeptic Pumping Slip - 895 Forest - Septic Pumping Slip - 895 FOREST STREET 10/3/2024 i
i
Commonwealth of Massachusetts
City/Town of
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 providod here, 9afore using this form, check with your
local Board of Health to determine the form They use. The System Pumping Record Plus[ be submitted to
the local Board of Health or other approving authority within 14 days from the pumping dale in
accordance with 310 CMR 15.351,
HOUSE: front bac id r2a� ie4t rigl�t� i
A—Facility Information Buil_DING: front back side rear left right
Important: jI
Important:When DECK: under
filling out forms 1. System Location.-
on the computer, c r
use only lho tab
key In move your Address —
cursor •donol /�
key
use the velum --- MA ( rr
. CllylTown V
—� �—�-.. Slala
Zip Code
2. System Owner-
Name
Address (If different from to.catfon) �-- ----
__ _MA_
CllylTown Slalo — Zip Codc
Telephone Numbei
B. Pumping Record
I. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank Tight Tank ❑ Grease Trap
❑ Other (describe); 1
4. Cffluent Tee Filter present? ❑ yes Vl No If yes, was it cleaned? ❑ yes ❑ No
5, Observed condition of component pumped;
/U
6. Syslem Primped 13y:
{have Tiney Mass 1 AA951Mass 1 X93-1
Name Vehicle license Nvm
Bateson f nterf�rises, Inc.
Company
7, G� IOrI Whefe CQntentS WBfG disposed:
C
_S
5ignalure o,
HA—Wet-Dale
S§gnalure of Rece!vfng I acility(ore#tacit facihly receipt} Gate
l5form4,doc, 11112
System Pumping Record Page 1 of S