HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 43 JAY ROAD 5/24/2024 Commonwealth of Massachusetts TV, WOW
C ity/Town of
a System Pumping Record
Form 4 MAC 2 41024
�M J•
DEP has provided this form for use by local Boards of Health. Other forms may be used, but t, ont
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. ------
HOUSE: front ack side rear, left right
A. Facility Information BUILDING: ont back side rear eft right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your rA�d s �y, ��
cursor-do not {� Cx�V MA l l U
use the return key. City/Town State Zip Code
2. Sy t m Owner:
Name
,enm
Address(if different from location)
MA
Cityrrown State Zip Code
Telephone Number
B. Pumping Record /
1. Date of Pumping 2. Quantity Pumped:
Date 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 condi 'on of component pumped:
6. System Pumped By:
Dave Tin_ey Ma 1AA95E Mass 1AD31Z
Name Vehi le License N ber
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
CCGLS _
22 2
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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