HomeMy WebLinkAboutSeptic Pumping Slip - 10/30/2024 - Septic Pumping Slip - 51 HAY MEADOW ROAD 10/30/2024 ` v Commonwealth of Massachusetts
City/Town of
- 5_ ystem Pumping Record
Form 4
PEP has provided this foram for use by focal Boards of Health, Other farms 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 -he pumping date in
accordance with 310 CMR 15.351 �...... -..__. Crigh)
HOUSE front back sid rear ,left
A. Facility Information BWI-DING. front back side rear left right
Important: Wizen DECK: under
filling out forms 1. System Location
cation:
on the
use onlyly the the tab iab
key to move your AdU ass ®V
cursor -do no( y /
use the return - —_ .__. __ _ MA
key" Cllyir'own state Zip Code
2 Systern Owner:
Name
r ,
lBIUI)
Addross (if difieront tram iocalivn}
_M A,
Y State --
Code
Telephone Number
�.._..__._...------
.._
B. Pumping Record
1. Date of Pumping Deie .__...._-- 2, Quantity Pumped _._. ._... .._ ... --
Gallons
3. Component: ❑ Cesspool(s) Septic 'rank ( Tank Tight
g ❑ Grease Trap
0 Othler (describe): _.._.-__. .__ _ ...
4. Effluent Tee Filter present? 61<s [__] No If yes, was it cleaned? No
5 Observed condition of cot-riponent pumped
6. System) Purnped By.
Dave They Mass 1AA95F_- Mass 1AD3'1Z.
Name Vr hic ie license: Number
Baresan Enterprises, Inc.
Company
7 Location where contents were disposed.
GLSD
Signature of N er Da W,
.. . ...............
signature of Receiving Facility (or attach facility receipt) Date;
15tor014,doC' 11112 >ystern Pumping Record Page 1 of 1