HomeMy WebLinkAboutSeptic Pumping Slip - 45 Beechwood - 10/25/24 - Septic Pumping Slip - 45 BEECHWOOD DRIVE 10/25/2024 _
Commonwealth of Massachusetts
City/Town of
t
System Pumping Record
a- Form 4
DEP has provided this form for use by local Boards of Health. Other forrns may be used, but the
information must be substantially the sarne as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pur'nping 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 back side rear left right
A. Facility Information BUILDING: front back side rear left rig",t
Important: When DECK: under
tilling out forms 1. S s m Location:
on ttie compel€3r,
use only the tab .......... .
__.
key to move your F�roswscursor-do no( MAuse the retufn key, slate Z,ip Code
2. System Owner
N
lelarn 'r�
Address Qf dlfteronl (corn location)
MA
CItyCTawax State -
Gip code
Telephone Number
B. Purnping Record - _
C _1. Date of Purnpinq Daie- -- __ _... _. 2 Quantity Pumped.
Gallons _ ----------
:3. Component'. Cesspool(s) Septic Tank C Tight Tank
g ❑ Grease Trap
(_ Other (describe):
4, Effluent Tee Filter present? [ Yes Uo if yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component purnped:
6 System Flurnped By
Dave 1 iney_ . Mass 1AA95E- Mass 1AD31Z
_ _-.. -- .... _ ..—_......
Name Vr hicle License Number
Baieson Enterprises, Inc
cor77pany
7 Location where contents were disposed:
C3 L S tJ
--
_ -- _..
Signature of Neuter Datr _ _ ..... . _
__...—
Signature of Receiving Facility (or atiach (aciiiry (eceipt} (late
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