HomeMy WebLinkAboutSeptic Pumping Slip - 40 Equestrian Dr - Septic Pumping Slip - 40 EQUESTRIAN DRIVE 9/25/2024 Commonwealth of Massachusetts 1
City/Town of
r"
System Pumping Record
Form 4
DES' 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 must be submlUed to
the local Board of Heaith or other approving authority within 14 days from ,he pumping date In
accordance with 310 CZAR 15.351.
HOUSE: Pro
beck stele rear left right
A. Facility Information SUILD2I, , back side rear left right
Important;When DECK: under
ruling oul forms 1, System location:
on the computer, r ti
use only tine tab
key to move your Addross
cvrsor-do not
use Iho return n (t MA �� KS
key. Clly/Town slaie Zip Code
2, System Owner: `(
Name
ulun
Address (if different from locallon)
MA
Gityrroivn Slate 21p Code
y<�
Telephone Numbef
B. Pumping Record C
1. Date of Pumping Date2, Quantity Pumped:
Gallons
3. Component: ❑ cosspool(s) Septic Tank ❑ Tight Tank
g ❑ Grease Trap
❑ Other (describe):
4, Effluent Tee Eliter present? ❑ Yes [ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed
;condition of component purnped;
6, System Pv.n).ped By:
Dave Tines _Mass 1AMN Mass 1AD31Z
Name Vehicle t_lcense um er
Baieson Enterprises, lu.
Company
7, do where contents were disposed:
GISD
°t T-,?jw?'
S's nalu€e of Habier uJ
9 Date
Slgnaturo of f�eceiving Facl4lly (or attach facility receipt) Date
t5form4.tloc 11112 Syslern Pumping Record Page 1 of t