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HomeMy WebLinkAboutSeptic Pumping Slip - 350 Forest - Septic Pumping Slip - 350 FOREST STREET 10/16/2024 Commonwealth of Massachusetts City/Towr1 of System Pumping Record r �, 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 idealth or other approving authority within 14 days from -.he purnping date in accordance with 310 C M R 15.351. ._____. _.....__.-.._...___ . _. HOUSE: front bac side, rear left ' h A. Facility Infort-nation BUILDING: front hark side rear left g t Important:When DECK: under filling out forms. System Locatic on lire computer, e-2� P a ;() use only the tab _ Rey to move your did mess Cursor-do nut A, M use t I e return _'..-_ -. __ ----.__, .... __.._._ key Cityrrown State Zip Code ?_. S stern Owner: > - -- Narne _— r=-21 X2 Address (if differ©-n from location) MA CI(y(Town State t!�t{�, ode L Telephone Number B. Pumping Record 1, Date of PUrriping 2. Quantity tyP r 1peC.Date Gallons 3. Component F-3 Cesspool(s) eptic Tank ❑f Tight Tank [I Grease Trap (. Other (describe): 4. Effluent Tee Filter present? Ej Yes No If yes, was it cleaned? [] Yes ❑ No 5. Observed condition of component pumped: 6. System Pumped By. Dave Tiney Mass 1AA95E Mass 1AD31Z Name Vehicle license Number Bateson Enterprises, Inc. (Snipa-ny 7. Location where contents were disposed (3L5D ,Signature of Ha Ill /B� Signature of Receiving Facility (or attach facility receipt) Date --- — f5form4.doc' 11112 S)ystern Pumping Record •Page 1 of 1