HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 162 HAY MEADOW ROAD 9/21/2023 Commonwealth of Massachusetts
City/Town of M�N�
System Pumping Record ��NOEpPR� ti1ti0ti3
Form 4 NEF S�Q
M
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 ba�Serear leftrightA. Facility Information BUILDING: front arear left right
Important:When DECK: under
filling out forms 1. System Location.
on the computer,
use only the tab tc., ? _ V L'c'L4
key to move your Address —(
cursor-do not MA
use the return tl'Q(� —
key. City/Town State Zip Code
2. System Owner:
Name
mnm
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
-A
1 Date of Pumping —q/S - 2. Quantity Pumped:
Date Gallons
3. Component. ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed conditi n of component pu ped:
r
6. System Pumped By:
Dave Tiney Ma F5821 Mass 1AA95E
Name Veh a Lice umber
Bateson Enterprises, Inc.
Company
7. ation where contents were disposed:
GLS
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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