HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 164 MILL ROAD 6/10/2024 Commonwealth of Massachusetts -�o,���ne � j�► WOW
City/Town of
a
System Pumping Record JUN 1 Q 2024
Form 4 }
�1 sA}},, r1td�int
DEP has provided this form for use by local Boards of Health. Othek"'4 betused, 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.
HOUSE: front Gacside rear left right
A. Facility Information BUILDING: front back side rear left rlg t
Important:when DECK: under
filling out forms 1. System Location:
on the computer, �^ C M
use only the tab 6 1/
key to move your Address
cursor•do not �j, (�d(,q� MA use the return Cil rrown
key. y State Zip Code
2. Sy tem Owner:
(l r W. 11 %-�n�f
Name
in�vn
Address (if different from location)
MA
Cltyrrown State Zip Code
_ Telephone Number
B. Pumping Record EE
1. Date of Pumping Da�O�Y 29 2. Quantity Pumped: �s�
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 conditi n of component pumped:
f rin4.
6. System Pumped By:
Dave Tiney Ma �19�x Mass 1 AD31 Z
Name Vehl a Ucense umber
Bateson Enterprises, Inc.
Company
7. nLtion where contents were disposed:
�C'M?
Signature of Hauler Date I
Signature of Receiving Facility(or attach facility receipt) Date
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