HomeMy WebLinkAboutSeptic Pumping Slip - 98 Forest St - 10/30/2024 - Septic Pumping Slip - 98 FOREST STREET 10/30/2024 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 some 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 15351.
b a_'�HOUSE: fron "' ""CR) side rear left (i95
A. Facility Information BUILDING: front back side rear left right
Important: When DECK: under
filling out forms 1. System Loca ion:
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return MA
key. CityfTown State Zip Code
2. System Owner:
IWO V'tu"
Name
Address (If different from location)
MA
C1tyfTown Zip Code
_t_�1_ep_hone Number
B. Pumping Record
1, Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
[] Other (describe):
4, Effluent Tee Filter present? E] Yes A No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. Systern Pumped By:
Mass I AD31
Dave Tlne Mass IAA95E
Name Vehicle License Nu$�Q_b§�E
B ate son EntegCIses,
Company
7. (LGcption where contents were disposed:
GLS
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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