HomeMy WebLinkAboutSeptic Pumping Slip - 990 Forest St - 11/27/2024 - Septic Pumping Slip - 990 FOREST STREET 11/27/2024 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 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: QQf�ron �, back side rear left ig
A. Facility Information BUILDING: rant
nt back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab C�C�o
key to move your Address
cursor-do not �) . PI/I MA
use the return CityrTown State Zip Code
key.
2. System Owner:
IV\
Name
Address(if different from location)
MA
Cityrrown State Zip Code
co 1� 75 11
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: 7 Cesspool(s) Septic Tank 7 Tight Tank 7 Grease Trap
7 Other(describe):
4. Effluent Tee Filter present? [I Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component loulmped:
P61
6. System Pumped By:
Dave Tiney Mass 1AA96E Mass 1 AD31
Name Vehicle License Numb&��
Bateson Enterprises, Inc.
Company
7. Ion where contents were disposed:
(GL S�D
Signature of Hauler Date
_Signature of Receiving Facility Facility(or attach facility-receipt) -Date
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