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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 t5form4.doc• 11112 System Pumping Record•Page 1 of 1