HomeMy WebLinkAboutSeptic Pumping Slip - 704 Forest St 9.10.2024 - Septic Pumping Slip - 704 FOREST STREET 9/10/2024 Commonwealth of Massachusetts
P City/Town of
System Pumping Record
1 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. 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: (�r7�
side rear left right
A. Facility Information BUILDING: side rear e right
important:When DECK: under
tiling out forms 1. System Location:
on the computer,
use only the tab
key tp move your Address
cursor-do na � ��- MA
use the return. IL
key City/Town State Zip Code
r r i 2. System Owner.
Name
,t
Address (if different from location)
MAI
A 5 r`'c
City[Town State Zip Code
-7` as-
Telephone
Number
B. Pumping Record
i. Date of Pumping 1D 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 condition of component pumped:
5. System Pumped By:
Dare Tiney jVehL
ss 1AA95 Mass 1AD3`?Z
Name se Number
Bateson Enterprises, Inc.
Company
7 ion where contents were disposed.
GLSD
C� to
Signature of Hauler Nate
Signature of Receiving'Facil€ty(or attach facility receipt) Date
t5form41.doc- 11112 System Pumping Record - Page 1 of 1