HomeMy WebLinkAboutSeptic Pumping Slip - 295 Rea St - Septic Pumping Slip - 295 REA STREET 10/21/2024 e,I
ILL-\ Commonwealth of Massachusetts
p, City/Town of
S 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. Bafore 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: frant(�ba(k ;de rear left 6ht
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 ZJ5— .�e,, 5 .--
key to move your dres
cursor-do not
use the return
key.
CityfTown State MA Zli5-Code
2, System Owner:
Name
-kii-res-s-(if different from location)
MA
'70W
State Zip Code
L
Telephone Number
B. Pumping Record
Lt
1, Date of Pumping 2 2. Quantity Pumped:
Date Gallons
3. Component: 7 Cesspool(s) Septic Tank 7 Tight Tank 7 Grease Trap
[—I Other (describe):
4. Effluent Tee Filter present? Yes7j� No If yes, was it cleaned? Yes 7 No
5. Observed condition of component pumped:
/V N-, ------
6. System Pumped By.,
Dave Mass 1AA95EX 1ADI
Name Vehicle License tuber
Bateson Enterprises, Inc.
Company
7. oc 'on where contents were disposed:
oc
GLS
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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