HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 31 LACY STREET 4/29/2024 Commonwealth of Mas5a`chusetts y. �, wS� And"'
City/Town of
x System Pumping Record'Form 4 APR 2 g 2 02
4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the `.ant
information must be substantially the same as that provided here. Before uVt' this•form, check with your
local Board of Health to determine the form they use. The System Pumping Record mush be submitted to
the local Board of Health or other approving aulhority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
HOUSE: front :back side rear left right
A. Facility Information BUILDING: ront ack side rear leh right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, 3t / �J+
use only the lab �. y
key to move your Addre r
cursor•do not
use the return MA ok%1Is
key. city/Town State Zip Code
2. System Owner.-
Name
nnrn
Address (if different from location).
MA
City/Town Slate Zip Code
Telephone Number
B. Pumping Record
1. Dale of Pumping Date 2 2. Quantity Pumped: �a
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4• Effluent Tee Filter present? ❑ Yes t No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed conditrion.of component pumped:
Va ram`
6. System Pumped By:
Dave Tiney Mass F8821 Mass 1AA 5E
Name Vehicle License umber
Bateson Enterprises, Inc.
Company
7. oc ion where contents were disposed:
GLS
SlgnaHauler Dale ae
Signature of Receiving Facility(or allach facility receipt) Dale
15form4•doc- 11/12
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