HomeMy WebLinkAboutSeptic Pumping Slip - 70 Brookview - 11/11/24 - Septic Pumping Slip - 70 BROOKVIEW DRIVE 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 CM R 15.351.
HOUSE: fron back' side rear le right)
A. Facility Information BUILDING: front Clack side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab 7o
key to move your Address
cursor-do not P (-),, MA
use the return City[Town State Zip Code
key.
2, System Owner:
Name
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ILI 2. Quantity Pumped:
Date Gallons
3. Component: 7 Cesspool(s) Septic Tank 7 Tight Tank 7 Grease Trap
Fj Other(describe):
4. Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed conditi of,component pumped:
6. System Pumped By:
_Dave Titjey_..__ MassKA��95E,'' Mass 1AD31Z
Name Vehicle 0-cts�mber
Bateson Enterprises,.-Inc.
-60—M-pa—ny --
7. o tion where contents were disposed:
G PLS D -—-------
Signature of Hauler Date
Signature of ReceivingFacility(or attach facility—receipiF----
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