HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 146 DEER MEADOW ROAD 10/24/2023 Commonwealth of Massachusetts
City/Town of
7 SYStem Pumping Record
`w 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: ron back side rear left right
A. Facility Information BUILDING: front back side rear left rig t
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab L Q, 4 N
key to move your Add r ss
cursor-do not ,[
use the return __ MA
key. City/Town State
Zip Code
2. System Owner:
,� ,�a6 q1V-_��
Name
ntun
Address (tf different from location)
_ MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping -- 2. Quantit Pumped.
Date y p 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? J/J Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mas F5821 Mass 1AA95E
Name vemci icens umber
Bateson Enterprises, Inc.
Company —
7. .on where contents were disposed:
GLSD ��
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Signature Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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