HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1493 FOREST STREET EXT 8/19/2024 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: front back side rear left right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
on:
filling out forms 1. System Locati
on the computer,
use only the tab 10 Uy i,cAl
key to move your S-s-
cursor-do not MA 0 A
use the return Ir y-
key. Cityfrown State Zip Code
2. System Owner:
rob CAA V A, a)
Name
rerun
Address(if different from location)
MA
CityfT own State Zip Code
-Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: 00
kDeq—�L) Al Gallons
3. Component: 7 Cesspool(s) Septic Tank M Tight Tank F1 Grease Trap
R Other(describe):
4. Effluent Tee Filter present? M Yes F1 No If yes,was it cleaned? F] Yes [] No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tin ln�e Mass 1AA95E Mass 1AD31Z
Name Vehicle License Number
Bateson Enterprises, Inc.
Company--
T. Location where contents were disposed:
GLSD Signature of Hauler
-Signature of Receiving Facility(or attach facility receipt) Date
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