HomeMy WebLinkAbout7 Fuller Meadow Road - Septic Pumping Slip 2024.09.18 - Septic Pumping Slip - 7 FULLER MEADOW ROAD 9/18/2024 Commonwealth of Mlassachusetts
�u C;tv,"Town of
System Pumping Record
� Form 4
DEP has Provided this form for use by Iocai Boards of Health, Other forms may be used, but the
information must, ve subsilantially the same as tnat , `ovdded here. Before using this form; check with your
local ward of health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving Gu t ri(, i thi:n ^q days from
roM -he pumping date In
accordance with v 1 n L.M "5.35"
i
I--0 Ul SF: from ck side rear leFt igh
A. Facility Information BUIID'iNG: front back slue rear left - gh
Important: When DECK: under
filling out forms 1. S-s,ek Cation:
on the comuter,
use o -y t e tat- `w
key to move your A cress
cursor-do no[ � j
use the return (
' F4— '�:- MA j
key.
,ty;'own State Zip Coc+e
3 L. System Owner:
IV
r
Name --
i
Address (f different from locatlonr
_ MR
vityfFcr�n State Zip Code
?eleohone Number
B. Pumping Record
1. mate ',£ Piumcing — 2, 'Ua!ltlt'J Pura a
- Date ped: Gallons
�. component: �,esspool(s) Septic Tank El Tight Tank a Grease Trap
Other (describe': -- —
a. i=ffiuent Tee Filter present? ❑ Yes No if yes, was it cleaned? ❑ Yes No
5. Observed condition of component pumped: {
f �
6. SVstern Pu1mQed Bv-
Dave Tiney Mass !AA95E Mass 1AD317
Name Vehicle License Number
BatPs^n Enfprprlses, Inn,
Company
roc n where -onten�e dispose-.
Signature of+;a: air§. ._ — ,ate
JIQn2ttir@ of—Re-V It?G Fa ,t"v attaC?1 fa 'iy'e Viet Date _
t5form4.doc- 11r1Z System Pumping Record,Page 1 of