HomeMy WebLinkAboutSeptic Pumping Slip - 962 Turnpike St - 11/1/24 - Septic Pumping Slip - 962 TURNPIKE STREET 11/1/2024 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 some 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 CMR 15.351,
HOUSE: front C6-c side rear lef(r�li
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location,
on the computer, C'
use only the tab I >? Co
key to move your Address
cursor-do notMA
use the return ------
key, CityrTown State Zip Code
2. Sy�5 em Owner:
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erent from location)
MA
Zip Code
elphone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped.
'bate-- -d—allons
3. Component: F7 Cesspool(s) Septic Tank 7 Tight Tank ❑ Grease Trap
0 Other (describe): ------
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? 7 Yes 7 No
5. Observed condition of component pumped:
6. Systern Pumped By.
Dav��T n Mass 1AA95E "/Mass 1A 3T
_iey
Name Vehicle License Nu ber
Bateson Enterprises, Inc.
Company
7. (4a�ation where contents were disposed:
Signature of Hauler Date
Signature Receiving Facility(or attach facility receipt) Date
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