HomeMy WebLinkAboutSeptic Pumping Slip - 96 Farnum - 10/31/24 - Septic Pumping Slip - 96 FARNUM STREET 10/31/2024 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. eafore 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 16.351. -------
HOUSE: froni�Laqjb side rear lelt-IJib
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab computer, - '
key to move your Address
cursor-do not
use the return
key. CityfTown MA State Zip Code
2. System Owner:
M 41 C,
Address(if different from location)
MwA—
C(k (Town
' Zip codes1e
mm
telephone Number
B. Pumping Record
1, Date of Pumping 2. Quantity Pumped'.
Date Gallons
3. Component: ❑ Cesspool(s) 5-711 Septic Tank 7 Tight Tank ❑ Grease Trap
❑ Other (describe):
4, Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? ❑ Yes ❑ No
?L
5. Observed condition of component pumped:
6. System Pumped By:
_Dave Tines ................. Mass 1AA95E AVIa's-s"1 A D,31Z,
Name Vehicle License N ber
Bateson Enterprises, Inc. .M
Company
7. 1 t. n where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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