HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 82 RALEIGH TAVERN LANE 7/17/2023 Commonwealth of Massachusetts o�2�e� 1)s
w City/Town of
a 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.
A. Facility Info tion
Left Right front of house, Left/Right rear of house, Left/Right side of house, Under C
Important:When Right side of building, Left/Right front of building, Left Right
rear of building,
filling out forms 1. System Location: / g g g
on the computer, 99 `
use only the tab 0 f--- To'
Ve�-n Ih
key to move your Address
cursor-do not N . MA
use the return City/Town State Zip Code
key.
2. System Owner: (�
ren mk('Y
Name
serum
Address(if different from location)
MA
City[Town State Zip Code
S'l Fs�l6- 91-40
Telephone Number
B. Pumping Record
1. Date of Pumping pas Z 2. Quantity Pumped. Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): ,(
4. Effluent Tee Filter present? ❑ Yes/
es J�1 No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed conditi n of component pu/mped:
c�
6. System Pumped By:
Dave Tiney Mass F5821 /,�:
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Name Vehicle License tuber
Bateson Enter rises, Inc.
Company
7.Scawhere contents were disposed.
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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