HomeMy WebLinkAboutSeptic Pumping Slip - 88 Pheasant Brook - Septic Pumping Slip - 88 PHEASANT BROOK ROAD 10/4/2024 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use by focal 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 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 back ide rear left nigh
A. Facility Information BUILDING: front back side rear left right
Important;when DICK: Under
filling out forms 1. System Location:
on the computer,
Use only the tab _ %e 't11'
key to move your Vas
cursor-do not . � �'.1`t�' MAC
use the return Cltylrown State Zip Code
key.
2. System Owner:
Sew tiC-Gu�f`t.
Name
,ten
Address(if different from!ovation)
_ MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
ry
1. Date of Pumping Date +� 2. Quantity Pumped: Gallons `
3. Component. ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
�4. Effluent Tee Filter present? El Yes
[� No if yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
rM�
6. System PtAmped By:
Dave Tin Mass 1AA95i^ Vlas$ 1AD31
ey Z
Name Vehicle License Nu ber
Bateson Enterprises, Inc.
Company
7. eatipn where contents were disposed:
G LS
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Bate
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