HomeMy WebLinkAboutSeptic Pumping Slip - 100 Raleigh Tavern - 10/30/24 - Septic Pumping Slip - 100 RALEIGH TAVERN LANE 10/30/2024 Comm onwealth of Massachusetts
W City/Town of
System
S y Pumping Record
Form 4
DCP 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 ",he pumping date in
accordance with 310 CMR 15 351
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-_- .-_ k side rear le ri5!~It
A. FacilityInformation BUILDING, front back side rear lefit r t
Important:Whan DECK: under
filling out forms LOG tlon.
on the computer, �
use only the tab
key to move your Address _.._
cursor-do nor MA ( r
use the return
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ke Cllyl�own stare Lip Code
7. ystem Owner:
f rBb
Address If different iron) location) -- ------_ __.-_
MA
Clty(Towri State Zip
_
Telephone Number
B. Pumping Record ��~~
1. Date of Pumping ___.._..-------- _ 2 Quantity Pumped
Date Gallons
3, Component: Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
Other (describe):
4, Effluent Tee Filter present? ❑ Yes _ o If yes, was it cleaned? ❑ Yes [ ] No
5. Observed condition of cornponenl purnped.
F. System Purnped By
Dave They___ -.. Mass 1AA95E Mass 1AD31Z
Name Vehicle license Number
Bafeson Fn�erprlses, Inc
company
7 Location where contents were disposed.
G,LSD
--
Signature of Hauler Date
_....... _.--.. -. ._.. -._ ._ . —.
- -
5dgnature o Receiv r7g <�cilily (or rsktact'o fac.iliry receipt) Dat<,
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