HomeMy WebLinkAboutSeptic Pumping Slip - 326 Forest St - 9.17.2024 - Septic Pumping Slip - 326 FOREST STREET 9/17/2024 0 M M o nA1 a 1 t h of M a.,--Is
ity
i own o'
SYStem Pumping Record
Form 4
DtEP nas Provided this form to, use by Oval Boaid3 of Health, Olt---er form,-- may be used, but the
information must be suristanii2ily the same 2S fh2f provided here, Pofore uSinq th!& loern, cnec', with Vour
local Board of Health to determine the for;; they use, The System Pumping Record must be submit-te'd to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 3 1 0 CMR 15,351.
A. F - HOUSE: (Dr , back side rear left CD
acuity Information BUILDING: front back side rear lle'-t righ'
impor-tant:When DECK: uncIp7r
[Ming oull forms
System Locanon,
on the computer
use only the tab' -yzc
key to move yQur Address
lujlsof -do not
use the return -b I MA
key, cily/Town
zip-Code
2. System Owner
rerern
Address, (If-d1tf1,,.M from ioca,ionj
MA
Telephone Number
B. Pumping Record
1, Date of Pumping
Dale 2. Quantity Pumped: Ga�lions -
3 Component Cesspool(s) Septic Tank ID Tight Tank Grease Trap
Other (desciibe)
4. affluent Tee POter 1present-r Y e s ❑ No yes, was it cleaned? Yes [] No
5, Observed condition of con-if)onen! pumped:
�j ire;it
& System Pumped By
Z
Name Vehicle Lieans tuber
Bateson Enterprises, Inc.
Company
7 hon f, w h
liefe contents were disposed,
lie
GLSD
Sig n a 11 u le , Hl a-..j,11 e t Date
Signature of Receiving Facility (Qratiach facilhfv eCeiD, 1)
ate
[5forrn4,doc. 11/12 System Pumping Record • Page 1. of 1.