HomeMy WebLinkAboutSeptic Pumping Slip - 230 Forest St - 12/3/2024 - Septic Pumping Slip - 230 FOREST STREET 12/3/2024 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. -7"'HOUSE: front ack side rear left right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms I, System Location'.
on the computer, C-A
use only the tab 4--
key to move your Address
cursor-do not �j MA
use the return
key. City/Town State Zip Code
2. System Owner:
j rye
rrr Name
g
tvirl)
Address(if different from location)
MA
Cityrrown State Zip Code
S-t., i t -------
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:Uate Gallons
3. Component: ❑ Cesspool(s) Septic Tank [7 Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? ❑ Yes D No
5. Observed condition of component pumped:
----0--64-,ttzj- ------ ----------
6. System Pwmped By:
_gave Mass 1AA95E 6ass 1AD3
Name Vehicle License Nurnbel-�
Bateson Enterprises, Inc.
Company
7. L- ation where contents were disposed:
GLS
Signature of Hauler
Signature of Receiving Facility(or attach facility receipt) Date
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