HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 51 HAY MEADOW ROAD 10/30/2023 L\ Commonwealth of Massachusetts
City/Town of
o 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. —` g
HOUSE: iron bac 'de rear le ri ht
A. Facility Information BUILDING: front ack side rear left right
DECK: under
Important:When
filling out forms 1. System L cation:
on the computer,
use only the lab �. —
keycur to move your Addr�es� � —
cursor-do not MA
use the return Cilyrrown Slate Zip Code
key.
2. System Owner:
Name
Address (if diHerenl Irom location)
_ MA Cil _
yrrown ---- Slate — --_ -Zip Code^
Telephone Number
B, Pumping Record
1. Date of Pumping fd Z�'=� ---- 2. Quantity Pumped: Gallons
Date
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): f
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condi Ion of component pumped:
6. System Pumped By:
Dave Tines Mas F5821 Mass 1AA95E
Name Vehicl Livens umber
Bateson Enterprises, Inc.
Company
7. ation where contents were disposed:
G L
61)17 le-) 47 -
Signature of Hauler Date
Signature of Receiving Facility(or allach facility receipt) Date
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