HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 316 RALEIGH TAVERN LANE 6/10/2024 Commonwealth of Massachusetts A u
C ity/Town of
a
System Pumping Record SUN 2024
Form 4
M n¢4 Sa
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 bac side rear le rig
A. Facility Information BUILDING: front back side rear left right
Important;When
DECK: under
filling out forms 1. System Lort
tion:
on the computer,use only the tabil� �T a ugrll _
key to move your Address
cursor-do not P MA ` �r
use the return Cilylrown State Zip Code 1
key.
2. Syste Owner:
Name
loom --
Address(If different from location)
MA
City/Town State Zip Code
q11- 91-1-3j�a3
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2 1 2• Quantity Pumped: Gallons v
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
I 5. Observed co ition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E as�1AD31
Name Vehicle License Numbe
Bateson Enterprises, Inc.
I Company
7. on where contents were disposed:
rLS D
Z� Z
Signature of Hauler Date
i
Signature of Receiving Facility(or attach facility receipt) Date
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