HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 120 HAY MEADOW ROAD 6/10/2024 pndo1der
L4 Commonwealth of Massachusetts
City/Town of JuN 1 2024
System Pumping Record
Form 4
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, 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 (113 side rea le ' right
A. Facility Information BUILDING: front back side rear left right
Important:when DECK: under
filling out forms 1. System Location:
on the computer, t{ ,H1�✓ Je'
use only the tab 120 7 �COC.)
key to move your Address
cursor-do not MA t
use the return Cil !Town
key. y State Zip Code
2. System Owner:
Name
morn
Address(if different from location)
MA
Cilyrrown State Zip Code
°( 3L& -
Telephone Number
B, Pumping Record
,5W
1. Date of Pumping Da " 3 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank g ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed co dition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1 AA95E Mass 1 AD31 Z
Name Vehicle License Nu ber
Bateson Enterprises, Inc.
Company
7. n where contents were disposed:
GLSD
s �rrz,
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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