HomeMy WebLinkAboutSeptic Pumping Slip - 10 Stonecleave Rd - 11/4/24 - Septic Pumping Slip - 10 STONECLEAVE ROAD 11/4/2024 Commonwealth of Massachusetts
City/Town of
)7
System Pumping Record
Form 4
orr
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. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record rnust 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, -------------- ........ -------
HOUSE: front back sid( rea 01 right
A. Facility Information 8 U I L D I N G i front back side ''r-e'a' r left. right
Important; When DECK: under
fliling out forms 1. S stern�qcrtlon:
on the cornputer,
use only the tab
key to move your d ass
cursor-do not MA
use the return chyffown
key S(a(a Zip Code
2� Sys , Owner
),r�r L
Narne
Address (if different from location)
MA
cnyrrrSWn State
Code
telephone Number
B. Pumping Record
1. Date of Pumping
2 Quantity Pumped. -Gir
3, Component: Cesspool(s) �eptic Tank Tight Tank ❑ Grease Trap
❑ 01her (describe),
4, Effluent Tee Filter present? F] Y e s No If yes, was a cleaned? 7 Yes 0 No
5, Observed condition of component pumped
------------------------------------------------------------
6, Systein Purnped By
(Dave Tine-Y.. Mass !AAOSE Mass IAD31Z
I---------- ...... -------------------------------
Narne Vehicle License Number
B2teson Er7terr)risp,s, Inc,
Company
7 Location where contents were disposed�
GL5D
---------- ........... ----------------......
ignatwe of Haulcq�" Date
------------- ---------------
-S-1,g"r-)at—�jr-e-o--f--R--e(�-eiving aci rty or attach facility receipt) Date
t5lorrn4.doc- 11/12 System Purnping Record - Page 1 of 1