HomeMy WebLinkAboutSeptic Pumping Slip - Septic Pumping Slip - 69 OAKES DRIVE 10/11/2024 i
Commonwealth of Massachusetts
City/Town of
System Pumping Record
,r 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. Woro using this form, ehook 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 act side rear � right
A. Facility Information BUILDING: front back side rear left right
Important;When DECK: under
(filing out forms 1. System Location;
on the computer, t?'.S�
use only the tab 0 0
key to move your Address
cursor-do not MA C ,
use the return MA
State Zip Code
key.
2, System Owner:
fr' Name
�xern ,
r
Address (If different from location) _
MA
Cltyrrown State zip Code
Telephone Number
B. Pumping Record _._._..
1, Date of Pumping t t 2. Quantity Pumped: `
Date 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: j
6. System Pumped By; _
Dave TlnLe Y_ r f- ' ~Mass 1AA95'E Mass 1AD31Z
Name C e VeNq�emcanSe'37umber
Bateson Enterprises, Inc.
Company
7. L-ocation where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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