HomeMy WebLinkAboutSeptic Pumping Slip - 94 Sherwood Dr - 10/23/24 - Septic Pumping Slip - 94 SHERWOOD DRIVE 10/23/2024 Commonwealth of Massachusetts
City/Town of
I 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 ns 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 CIVIR 15.351.
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A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, 6
use only the tab
key to move your Address
cursor-do not MAr.
use the return
key. City[Town State Zip Code
2, System Owner:
Name
Address
MA
City/Town State Zip Code
IF e7 >-
-Telephone Number
B. Pumping Record
2. Quantity Pumped:
1, Date of Pumpingdata Gallons
3. Component: ❑ Cesspool(s) Septic Tank 7 Tight Tank 7 Grease Trap
❑ Other (describe): ——----- ......
4. Effluent Tee Filter present? ❑ Yes/6 No If yes, was it cleaned? F-1 Yes D No
5. Observed conditio of component pumped:
k/d�1.1"41
6. System Pumped By:
ave Mass 1AA95E ass-1 A-MI-Z--
Name Vehicle License Nu
Bateson Enterprises, Inc.
Company
7. Loza4"'on where contents were disposed:
G L,!S D
Signature of-4a-U-I—er Date
-'Signature-o-f-Receiving-'Fa�Mty(Wra7tt—ac-h'TicFIFCy--receipt)
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