HomeMy WebLinkAboutSeptic Pumping Slip - 80 Sutton Hill - 11/8/24 - Septic Pumping Slip - 80 SUTTON HILL ROAD 11/8/2024 Commonwealth of Massachusetts
City/Town of
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. 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.
HOUSE: front side rear right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling ❑
out forms 1. System Loc�tion.'
on the computer, �. �yy❑
use only the tab
key to move your Address MA
cursor-do not IN C n
use the return
key. City[Town State Zip Code
2. System O�w er:
Name
-Address(if different from location)
MA
CityrTown State Zip Code
Telephone
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: F7 Cesspool(s) Septic Tank F7 Tight Tank E Grease Trap
7 Other(describe):
4. Effluent Tee Filter present? 0 Yes No If yes, was it cleaned? ❑ Yes [] No
5. Observed condition of component pumped:
6, System PtAmped By:
Dave Tiney Mass 1AA95E ('aa--SS--1 A D3 TZ)
Name Vehicle License Numb4-- __.,-,'..1'�1
Bateson Enterprises, Inc.
Company
7. ion where contents were disposed:
❑GLSD
-Signature of Hauler Date
-Signature of Rectivin`gFa��M (or attach facility receipt) Date
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