HomeMy WebLinkAboutSeptic Pumping Slip - 224 Hay Meadow - 11/7/24 - Septic Pumping Slip - 224 HAY MEADOW ROAD 11/7/2024 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: front side rea<j�eft3 right
A. Facility Information BUILDING: front back side rear left right
Important;When DECK: under
filling out forms 1. Sy Z stem L7ocat'
on the computer, C"(
use only the tab 2 ,`(
key to move your Address
cursor-do not
MA
use the return
key. City/Town State Zip Code
2. System Owner:
CE
Name
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
'-�L lsrx-)
1, Date of Pumping Al "' 2. Quantity Pumped-
-bate Gallons
1 Component: M Cesspool(s) Septic Tank 7 Tight Tank F1 Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
,Dave Tine Mass 1AA951� Mass 1AD31z)
Name Vehicle License
,Bateson Enterprises, Inc.
Company
7. cc" I on where contents were disposed:
'c
GLSD
Signature of Hauler Date
-Signature of Receiving,Facility(or attach facility receipt) Date
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