HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 82 RALEIGH TAVERN LANE 8/5/2024 Commonwealth of Massachusetts 0%V eh ao\0
City/Town of _ lrj,40
a
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms mii`!ord
b R�the
information must be substantially the same as that provided here. Before usfiorm, check with your
local Board of Health to determine the form the use. The System Pumping must be submitted to
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the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351. --
HOUSE: ront back side rear 6e ' right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,use only the tab S (� �'Z @--, \, `Q-U�^
key to move your Address^ �
cursor-do not .6 MA 6G
use the return Clt !Town Ot
key. y State Zip Code
2. System Owner:
Arne
ieuvn
Address(if different from location)
MA
Cityrrown State Zip Code
Stier -
Telephone Number
B. Pumping Record
1. Date of Pumping ZY L 2. Quantity Pumped: `S
Date Gallons
3. Component: ❑ Cesspool(s) Q�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:
P6Ct,,((
6. System Pumped By:
Dave Tiney M s 1AA95E Mass 1AD31Z
Name V icle license Nu er
Bateson Enterprises, Inc.
Company
7, YM n where contents were disposed.
LSD
2
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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