HomeMy WebLinkAboutSeptic Pumping Slip - 148 Candlestick - Septic Pumping Slip - 148 CANDLESTICK ROAD 10/3/2024 Commonwealth of Massachusetts
f� City/Town of
- System Pumping Record
Forn-i 4
DEP has provided this farm for use by local Boards of Health. Other forms may be used, but the
information must be substanially the same as that providod here. Pefore using #his form, chock with your
local Board of Health to determine the form They use, The System Pimping 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,
HOWi front back side rear eft > h1
A. Facility Info 'matlOn W [3UItl7WG: rent back side rear e right
Important:When DECK: udder
IMIng uul lorms 1. System Location;
on the compuiaf, f (� {
Use only iha jab l r '- �C-,':�
key to move your Ad r ss --'"
cursor_do not ,�n MA
use the return MA
key. cilyfrown Slate -
Zlp Code
2, SyystomOwner:
lIItYR '
Address (If different from jocatipn)
CllylTown� - --- MA Staje YIP Code `__`
Teone tlum6er
B, Pumping Record
� l �S 1, Bate of Pumping Date ? --� 2. Quantity Pumped:
Gallons
3, Component: ❑ Cesspool(s) /�} Septic Tank ❑ Tsght Tank ❑ Grease Trap
❑ Other (describe),
4. Effluent Tee filter present? ❑ Yes/] No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped;
6, System Pumped By:
Dave Tine Mass 1AA95E "fillass 1 D31Z
Name Vehicle License N mbar —�
Bateson Enterprises, Inc. — —
Company —_�-
7, (ion where contents were disposed:
GLSD
Signature of Hauler Dalo
Signature of Receiving Facilily(orallach facility receipt} p.le --
l5lornl4,doc, 11112
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