HomeMy WebLinkAboutSeptic Pumping Slip - 49 Crossbow - 11/11/24 - Septic Pumping Slip - 49 CROSSBOW LANE 11/11/2024 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 CMR 15.351
HOUSE: I/rro7t, back side rear right
A. Facility Information BUILDING: �-�t back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab - t/� C<-65 -6Q
key to move your Address
cursor-do not
use the return MA
key. City/Town State Zip Code
2. System Owner:
Tame
fan
Address(if different from location)
_M A
Clty[Town State Zip Code
Telephone Number
B. Pumping Record 2Data . y '.
1. Date of Pumping Quantity Pumped
Gallons
3. Component: F7 Cesspool(s) Septic Tank 7 Tight Tank 7 Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? [I Yes ❑ No If yes, was it cleaned? 7 Yes ❑ No
5. Observed con I tion of component pumped:
6. System Pumped By:
_Dave TaneyMa s�1��95 Mass I AD31Z
Name 7eh le Lice umber
Bateson Enterprises, Inc.
Company
7. ation where contents were disposed:
GILS
7,
igna6_t6;_Hauler Da-t-e
"Sgna�tureo�fliiec�ivin���l�ae�iii (or attach facility receipt) ------ Date
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