HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 136 RALEIGH TAVERN LANE 5/21/2024 Commonwealth of Massachusetts rows of '
th
City/Town of oeAndOver
a System Pumping Record k4y2
Form 4 Zd24
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,_che'Q�k�cwith your
must local Board of Health to determine the form they use. The System Pumping Record be Amitted 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: front Pack
side rear right
A. FacilityInformation BUILDING: front side rear left right
Important:when DECK: under
filling out forms 1. System Loc Ion:
on the computer, r
use only the tab �� LJ2'r
key to move your Address
cursor-do not N MA
use the return City/Town State Zip Code
key.
rye
2. S tem Owner:
9err S �cr
Name
ielu7l
Address(if different from location)
MA
City/Town State � v �`��6 G ode
Telephone Number) 0
B. Pumping Record
1. Date of Pumping Date 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:
k)6rML(
6. System Pumped By:
Dave Tiney M s 1 AA Mass 1 AD31 Z
Name Ve icle License Nu bar
Bateson Enterprises, Inc.
Company
7. hcation where contents were disposed.
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1