HomeMy WebLinkAboutSeptic Pumping Slip - 261 Bridges Lane - Septic Pumping Slip - 261 BRIDGES LANE 10/1/2024 i
Commonwealth of Massachusetts
City/Town of
System Pumping Record
r Form 4
DEP has provided this fora for use by local Boards of Health. Other forms may be usQd, bul the
information must be substantially the same as that provided here. Before using [his 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 Heaith or other approving authority within 14 days from .he pumping date in
accordance with 310 CMR 16.351. _
wousl front bac irie ear left' right
A. Facility Information BUILDING: front back side rear left right
Important:when DECK; under
filling out farms 1. S st rn Location:
on the computar,
use only the lab _" mx
key to move your
cursor-do not GI MA
use the.alum t ll !Town r
�J�M
key, Y Slate Zip Coda
2, S stem Owner:
V �
�r Name — —
1
rrlwn
Addross (lf different from location)
MA _
Cily/Town Stale
Cod
Telephone Number
B. Pumping Record
1, Date of Pumping D r� �j l
p Date 2. Quantity Pumped: Gallons
3, Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe), —
4, Effluent Tee I"ilter present? ❑ Yes [ o j If yes, was it cleaned? ❑ Yes
IN
5, Observed condition of component pumped:
S. System Pgmped By:
Dave Tiney _Mass 1AA95E Mass 1AD31Z
Name Vehtele Llcense Number
Bateson Enterprises, Inc,
Company
7, Location where contents were disposed;
GL3D
Signature of Hauler Date
Signature of Recelving Facilfly(or attach facility receipt) Dale
1510fm4.doc, 11112 System Pumping Record-Page 1 of 1