HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 64 FOREST STREET 8/3/2026 Commonwealth of Massachusetts
=_ City/Town of
System C
y em Pumping Record
Farm 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 sarr�e 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 idealth or other approving authority within 14 days from the pumping date Ili
accordance with 310 CMR 15.351. ---
____. HOUSE: front hoc sidrear left right
A. Facility Information BUILDING: front back side rear left right
r DECK: under
Important: When
filling out forms 1. Sycte 0CaLion:
on the computer,
use only the tab ......... ------ --------------
key to move your Xac ress
cursor-do not MA
usethe return _-..._ _.......---__.._ --- — _.__._.__.._: . _ _..._..._-_ _.____----____
key City/Town State Zip Code
2. Systern Owner
Oe1. '
Address (If different from location)
MA
City/town State Z_i de
Telephone umber
. Pumping Record
1, Doke of Pumping Date T-Z2. Quantity Pumped: Gallons
1Component: ❑ Cesspool(s) tic Tank [❑ Tight Tank ❑ Grease Trap
❑ Other (describe),,
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condition of n ponent pum ad:c,
__.__.... ..._....._........
.___....__.
6. ystem Pumped By:
Dave Tine y Mass 1AA95E (r —
`,,2ateso-n--E-ls 1AD31Z
_._-._.. —.--- - ------ --_.._- ------ ------ ._._._
Name Vehicle License Num
Company Inc 7. 'location wh e co is w d i s m p
G CS,D.
Signature of Hauler pate
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc- 11/12 System Pumping Record • Paoe 1 of 1