HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 224 HAY MEADOW ROAD 11/4/2022 Commonwealth of Massachusetts ��EwE°
City/Town of _
A ° System Pumping Record NOv 4202'l
a
Form 4 �NAN�OjEA
tiOkA t;- TM
DEP has provided this form for use by local Boards of Health. Other f�Ks 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 �c side rear right
A. Facility information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. Sy em Locatio
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return '
key. City/Town
State Zip Code
2. System Owner:
ame
ienun
Address(if different from location) ___
city/town 7�fate _ -—
Zip Code
Telephone Number
B. Pumping Record - —
1. Date of Pumping ' 2 u �Sz_v_
Date Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
� 9 ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If es, was it cleaned?
y ❑ Yes ❑ No
5. Observed cond' ion of component pumped:
f�lalOt
6. System Pumped By:
Dave Tine Name y Mass 1AA95E
Bateson Enterprises Inc
Vehicle License Number
Company
7. Lo ion where contents were disposed:
LS
Signatu f Hauler
Date
Signature of Receiving Facility(or attach facility receipt) Date
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