HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 25 HOLLOW TREE LANE 3/15/2024 Commonwealth of Massachusetts =�
w City/Town of
System Pumping Record R 15 tioti�
Form 4 MP
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 In _ tion
Left/ ght front of house, Left/ Right rear of house, Left/Right side of house, Under[
Important:When
filling out forms 1. System Loc tin e / Right side of building, Left/ Right front of building, Left/Right rear of building,
on the computer, —Tg Qn y2_
use only the tab I x�� — --- - —
ckeyur to move your ,�ddqre�ss /� /�r&/
cursor-do not fLt)K "' �hJ�a MA — y G 0
use the return City/Town State Zip Code
key.
2. Svrktem Owner:
Name
nxm
Address(if different from location)
MA �j
City/Town State Code 1& f1/ Ka2
Telephone Number
B. Pumping Record
1. Date of Pumping Date —- 2. Quantity Pumped: aeons
3. Component: ❑ Cesspool(s) cp�eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): —-- -- -
4. Effluent Tee Filter present? ❑ Y�No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pu ped:
6. System Pumped By:
Dave Tiney Mass F584/1---AA IM 9 5 Q
Name Vehicle Licens
Bateson Enterprises, Inc. _
Company
7. Location where con t ere disposed:
GLSD
Signatur of HVITer Date
Signature of Receiving Faci ity(or attach facility receipt) Date
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