HomeMy WebLinkAboutSeptic Pumping Slip - 114 Stonecleave Road - Septic Pumping Slip - 114 STONECLEAVE ROAD 10/15/2024 Commonwealth of Massachusetts
City/Town of
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Sysfem 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 trust be submitted to
the locai Board of Health or other approving authority within 14 days from -he pumping date in
accordance with 310 CMR 15,351.
HOUSE, front back sicla rear left right
A, Facility Information BUILDING: Front Hack side ar left right
Important;When DECK: under
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2. Sys em Owner:
Aame
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Address (If difforont from location)
MA
clly(rown _ Stale
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Telephone Number
B. Pumping Record
1, Date of Pumping - 2. Quantity Pumped: —
Dale Gallons
3, Component: ❑ Cesspool(s) eptic Tank 0 Tight Tank g El Grease Trap
❑ Other (describe): _
4. Effluent Tee Filter present? ❑ Yes No if yes, was it cleaned? ❑ Yes ❑ No
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5. Observed condition of component pumped:
6, Syslen) Ptamped By:
Dave Tinay Mass 1AA95E Mass 1A031Z
Name Vehlc-e License Number
Bateson Enterprises, loc.
Company
7. Location where contents were disposed:
GLSD _
Signature of kiau r Data _ -
Signature of Receiving Facility(or attach lacili(y fecelpl) Dale -�
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