HomeMy WebLinkAboutSeptic Pumping Slip - 88 Sawmill Road - 9.9.2024 - Septic Pumping Slip - 88 SAW MILL ROAD 9/9/2024 Commonwealth of Massachusetts
p City/Town of
System Pumping Record
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 S2Me 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 authority within 14 days from the pumping date in
accordance with 310 CMR 15.3511,
right
HOUSE: Ir'�fro back side rear le
A. Facility Information `ik�<t back side rear left I BUILDING: right
important: When DECK: under
filling out forms 1. System Location:
or,the computer,
use only the tab
key to move your Address
cursor-do not
use the reel
MA urn 3
key. City/T own State Zip Code
yi�Q- 1 2. System Owner,
Name
BttYA -
Address (if different from location)
MA
City/Town State Zip Code
(I-
(4,5(P-
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped"
Date Gallons
3, Component: El Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
0 Other (describe):
4, Effluent Tee Filter present? i'_-_jl Yes I No if Yes, was it cleaned? [—I Yes E] No
5, Observed condition of component pu ed:
System Pumped By:
Dave Tiaiey Mass 1AA95 Mass '1AD3 Z
Name Vehicle license N(um;�
Bateson Enterprises. 'Inc.
Company
7, (,L7cistkon where contents were disposed:,
,LSD
Signature of Hauler Date
-signature of—Rec-ewlngFacility(or attach facility receipt; Date
t5form4.doc- 11,112 System Pumping Record - Page off!