HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 32 DEER MEADOW ROAD 10/24/2023 i Commonwealth of Massachusetts
w City/Town of
a System Pumping Record ®C�
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- . —'° g
----- ------ -----
HOUSE: frontG side rear(left ri ht
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, �1 Doeruse only the tab U. Me, <J
key to move your Address
cursor-do not t ) L��� _ _ MA
use the return —Cityrrown Slate Zip Code
key.
2. System Owner:
rd
"1 M 1 fM`ke/' - —
Name
Brun
Address (if different from location)
_ MA
City/Town State Zi Code
Telephone Number
B. Pumping Record
1. Date of Pumping to Ll ----- 2. Quantity Pumped: /S�
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 con diti n of component pumped:
r me, _--
6. System Pumped By:
Ma s�5821Dave Tiney Mass 1AA95E
e
Name Vehi License umber
Bateson Enterprises, Inc.
Company
7 ation where contents were disposed:
GLS
Signal re of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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