HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 80 PHEASANT BROOK ROAD 4/29/2024 Commonwealth of Massachusetts
City/Town of 2024
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'�i o!rr li s.�rl rr rf rr v� e a v v v Yw
Form V�4
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DEP has provided this form for use by local Boards of Health. Ot�Ar farms 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 Information _ _
Left/Right front of hous left ight rear-of house, Left/Right side of house, Under C
Important:When / h g g
filling out forms 1. Gtem Lo ation: Left/Right side of building, Right t front of building, Left/Right rear of building, .
on the computer, �L
use only the tab ✓� —_.____.. _..
key to move your A dress I
cursor-do not - MA _ •l/J)` Q
use the return -- _ _....._ —_-- ---__—•
key. y own State Zip Code
System Owner:
raD
Name
ercw .
Address(if different from location)
MA
City!Town Sfafp [7.ip Cndeq
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—
Teleph ne Number 7
R. Pumping Record
1. Date of Pumping ate - 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank Q Grease Trap
❑ Other(describe): ----- --------
4. Effluent Tee Filter present? CI Ye.. Nn If yes, was it cleaned? ❑ Yes ❑ No.
5. Observed condition of component pumpe
6. System Pumped By:
_Dave Tine_ - Mass F5821 _ ya
Name Vehicle License umber
Bateson Enterprises, Inc.
Company
L7. Loc ' where contents were disposed:
LSD
Signature of Hauler Ye
§ior'iNInrH of RHCFadvin(J. Fi4diity(Oi attach faciiiiy rircC 1pn Date ----- -- ---'--•--
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