HomeMy WebLinkAboutSeptic Pumping Slip - 101 Duncan - 10/31/24 - Septic Pumping Slip - 101 DUNCAN DRIVE 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. 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: (fro4 back side rear left C�ig�h
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms I System Location:
on the computer,
use only the tab tO
key to move your Address
cursor-do not
use the return �) A MA
key. City/Town State Zip Code
2, System Owner:
2 r-, L ........
(JAL
Name
Address(if different from location)
MA
-C-I—ty/Towiil- State Zip Code
-6-533
'telephone Number
B. Pumping Record Art-V
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3, Component: ❑ Cesspool(s) Septic Tank 7 Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? F� Yes ❑ No
5, Observed condition of component pumped:
6. System Pumped By:
jDave Tlney............. MasslAA95E Aft§'s"I"' 3 1 Z
Name Vehicle License Numbhfl-------",
Bateson Enterprises,
Company
7. Zton where contents were disposed:
I�D
Signature of
Signature of Receiving Facility—(or-attach facility receipt) Date
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