HomeMy WebLinkAboutSeptic Pumping Slip - 345 Raleigh Tavern - Septic Pumping Slip - 345 RALEIGH TAVERN LANE 9/25/2024 I
Commonwealth of Massachusetts
City/Town of _
_ System Pumping Record
Form A
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 pfovided 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 Health or other approving authority within 14 days from -he pumping date in
accordance with 310 CMR 16.351.
HOUSE: front back side rear le i�ht '
A. Facility information BUILDING: front back side rear ieft right
Important:Whan DECK: Linder
filling out forms 1. System Location;
Of)the eornpulor, [/�/�_ y�
rise only the tab !r.� '~v ! ''J��� �t� 1.41"
key to move your Address
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cursor-do not �� � f MA � �
use the relum Ch !Town
key, Y State Zip Code
441 z. S stem Owner:
Name
rrrwn '
Address(11 d4foront from locailo(j)
_ MA
Clly(Town m W Stale Zip Code
Telephone Number
B. Pumping Record
1. Date of Bumping ''`` 2. Quant#ty Pumped'
Dale aliens
3, Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank g El Grease Trap
❑ Other (describe):
4, Effluent Tee Filter present? ❑ Yes =,No If yes, was it cfeaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6, System Pumped By:
Dave Tiney - _M_a_ss 1AA95E _Mass 1AD31Z
Name Vehicle License Number
Bateson Enterprises,
Company
7. Location where contents were disposed:
GLSD
Signature r auler Dale
Signature of Recelvlr3g Facility(o(aliach facility fecelpl) bate
l5form4.doc, 11112 System Pumping Record Page 1 of I