HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 30 JAY ROAD 6/10/2024 Commonwealth of Massachusetts "
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City/Town of
System Pumping Record JUN 10 2�24
Form 4
DEP has provided this form for use by local Boards of Health. Other fprms 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 ack side rea ?eft)right
right
A. Facility Information BUILDING: back side rear
Important:when DECK: under
filling out forms 1. System Location:
on the computer, 0 S
use only the tab C
key to move your Address
cursor-do not P OL MA
use the return key. City/Town State Zip Code
2. System Owner:
�. S ,n•,ps�
Name
n�an
Address (if different from location)
MA
Cltyrrown State Zip Code
Telephone Number
B. Pumping Record
1 Date of Pumping ?4 2. Quantity Pumped:Da 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:
wl+"(
6. System Pumped By:
Dave Tiney Mass 1AA95 Ma�1AD31
Name Vehicle License umber
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:QGLS
Signa of Hauler Date ture
Signature of Receiving'Facility(or attach facility receipt) Date
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