HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 191 GRANVILLE LANE 3/29/2024 �doveC
Commonwealth of Massachusetts
City/Town of
�014
System Pumping Record MPR 29
Form 4 erg
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 usJng 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: fron back side rear left right
A. Facility Information BUILDING: front back side rear a right
Important:When
DECK: under
filling out forms 1. System Location:
on the computer,use only the lab 1 C�1 ( C2� \n V 1� 2
key to move your Address
cursor• not
use the return
urn w
� 1- ���� MA —Qt�y�
key. Cily/Town State Zip Code
2. System Owner:
D:4-LA
n�
Name
nnm
Address (if different from location).
_ MA
City/Town State
--b Zip Code
Telep one Number
B. Pumping Record
Z /cam 1. Date of Pumping ZCPDate 2. Quantity Pumped: 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 condition.of component pumped:
1vo�rti.L,(
6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA95E
Name Vehicle License Nu ber
Bateson Enterprises, Inc.
Company
7.(:: lion where contents were disposed:
GLS
Signature of Hauler Date
Signature of Receiving Facility(or allach facility receipt) Dale
15form4.doc, 11/12
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