HomeMy WebLinkAboutSeptic Pumping Slip - 62 Stonecleave - Septic Pumping Slip - 62 STONECLEAVE ROAD 10/22/2024 Commonwealth of Massachusetts
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 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❑a c'- side rea right
BUILDING: front back side
A. Facility Information rear eft right
Important;When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab 51,nec (X- cz.'
key to move your Address
cursor-do not " - (An MA
use the return City/Town State -Zlp Code
key.
2. Sy te Owner
Name
Address(if different from location)
MA —p �d--e
Cityrrown State
'Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: Gallons
3. Component: 7 Cesspool(s) Septic Tank 7 Tight Tank ❑ Grease Trap
M Other(describe):
4. Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? F Yes ❑ No
5. Observed condition pf component pumped:
06,r t�A
6. System Pumped By:
Mass 1AA96E --Gss 1 A-D3TZ,,,,
Name Vehicle License
Bateson Enterprises, Inc.
Company
7. 'on where contents were disposed:
LS
0 ------
Signature of Hauler Date
-Signature of Receiving"Facility(or attach
t5form4,doc,11112 System Pumping Record-Page 1 of 1