HomeMy WebLinkAboutSeptic Pumping Slip - 128 Mill Road - Septic Pumping Slip - 128 MILL ROAD 10/21/2024 L Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
PEP 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 horo. 1;oforo using this form, chook 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 backcsid rear left right
'L95g Q2
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab o v.I� �Ib
key to move your Address
cursor-do not
use the return
N �\0\1� �� -- MA
key, City/Town State Zip Code
2. System Owner:
� ,, __ _ _ _
Name
return ,�'V � ❑__�_ �_ ___ _� ___
Address ((f different from location)
MA
Cityf'rown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ti 2. Quantity Pumped-
DateGallons
ro
3. Component: ❑ Cesspool(s) Septic Tank 7 Tight Tank 7 Grease Trap
F1 Other(describe):
4, Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? ❑ Yes 7 No
5, Observed condition of component pu ped:
P 0
6. System Pumped By.
-
Mass 1AA95E (Mass 1AD311
Name Vehicle License
Bateson Enterprises, Inc.
Company
7, n where contents were disposed:
'LSD\
Signature of Hauler Date
_Signature of Receiving Facility(or ilfiach facility receipt) Date
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