HomeMy WebLinkAboutSeptic Pumping Slip - 97 Sawmill Rd - Septic Pumping Slip - 97 SAW MILL ROAD 9/23/2024 l
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Commonwealth of Massachusetts i
City/Town of
System Pumping Re-cord
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 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 aulhority within 14 days from -he pumping date in
accordance with 310 CMR 15.351,
HOUSE; front acl< side rear left' righ�
A. Facility Inforrnafion SUII.DING: back side rear left right
i
Important; Whorl DECK: under
filling out corms 1. Systern Location: E
on the cornputar,
use only the tab ICYw t*�
key to move your Addrasa
cursor•do not
use the slum MA
Cfi /Town
key. Y Stale Zip Code
2. System Owner:
ref
NameLAI"
Address (If dlfferonl from lacatlpn)
MA
CItYlt own State Zip Code
_ Telephone Number
B, Pumping Record
1, Date of Pumping pale Z� W 2. Quantify Pun�pecf:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank g ❑ Grease Trap
❑ Other (describe): -
4. Effluent Tee Filler present? ❑ Yes No If yes, was It cleaned? ❑ Yes ❑ No
5. Observed condition of component pu. pad:
6. System P(dmped By:
Dave Tineses ^_ `� Mass 1 AA95E Mass
Dame Vehicle License Nu fiber
Baleson Er}larrises,
Company W
7. Location where contents were disposed:,
GLS
Signature f Hauler Dale �—
Signature of Receiving Facility(of flitach facility receipt) Dale
l5fwmel,doo- I IM Syslern Pumping Record Page 1 of I