HomeMy WebLinkAboutSeptic Pumping Slip - 52 N Cross - 9.9.2024 - Septic Pumping Slip - 52 NORTH CROSS ROAD 9/9/2024 Commonwealth of Massachusetts
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City/Town of
j� System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health, Qther 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 authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
HOUSE: front ack side ea left right
A. Facility Information BUILD NG: front back side rear left right
important:When DECK: under
Riling out forms 1. System Location:
on the computer,
use only'he tab
Key to move your address
cursor-do not p`
use the return VA
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Key, Cityfrown State Zip code
? 2. System Owner:
ai Name
i i67tYtJ
Address (if different from location)
MA
GltyfTown State Zip Code
Telephone Number
B. Pumping Record
1. Gate of Pumping Date 2. Quantity Pumped:
Gallons
3. Component: ❑t Cesspool(s; Septic Tank ❑ Tight 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:
0. System Pumped By:
Dale Tsney Mass 1AA95 Mass 1RD31Z
Name vehicle License
Bateson Enterprises, inc.
Company
7. on where contents were disposed:
GLS
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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