HomeMy WebLinkAboutSeptic Pumping Slip - 769 Forest St - 11/8/24 - Septic Pumping Slip - 769 FOREST STREET 11/8/2024 Commonwealth of Massachusetts
cu 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 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: front('bac,k, side rear -left(ri90)
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, — '? I'll,
use only the tab --- f
key to move your Address
cursor-do not MA
use the return
key. City/Town State Zip Code
2. System Owner:
_t4 (44,
Address(ifd�Ti—fferenD'r- location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
/'(X
1, Date of Pumping -Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank 7 Tight Tank 7 Grease Trap
❑ Other(describe): —-—--------
4. Effluent Tee Filter present? El Yes No If yes, was it cleaned? F Yes 7 No
5. Observed condition
pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E ( Mass IAD31Z"�
Name Vehicle License Nurnb6r-,_
Bateson Enterprises,
Company
7. tion where contents were disposed:
LS
Signature of Hauler Date
---------........
- 7 Date
Signature of ReCeivTn�Fa Facility o c facility receipt)
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