HomeMy WebLinkAboutSeptic Pumping Slip - 250 S. Bradford St - Septic Pumping Slip - 250 SOUTH BRADFORD STREET 10/4/2024 li
Commonwealth of Massachusetts
City/Town of
System 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 [hat 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 aulhority within 14 days from -he pumping date fn
accordance with 310 GIViR 15,351.
_ HOUSE: front back side re a left nigh
A, Facility Information BUILDING: front back sid r r left
Important:When DECK; under
filling out forms 1. System Location: ��WMI
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on the cornpuler,
use only the tab __
key to move your ddrass
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keythe return Cil lTown Stale Zip Code
2. System Owner:
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Address (If(TKeront from location)
MA _
Cityrrown Slate7YK
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Telophona umber
B, Pimping Record —3-� ,
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1. Dale of Pumping ate - 2. Quantity Pumped: Ga#Ions
i
3. Xonent: ❑ Cess ol(s) ❑ eptic Tank [] Tight Tank g ❑ Grease Trap
Cher (describe); —
4, Effluent Tee Filter present? ❑ Ye No if yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. Systern Pumped By:
Dave Tiney Mass 1AA95F Mass 1AD31Z
Name Vehicle t_Ecense Number
Bateson Enterprises, Inc.
Company _
7, Location where contents were disposed:
Gt_3D
signature of Haul ----- Dat
Signature of Receiving Pac'tllty(or attach facility recelpo Bate
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