HomeMy WebLinkAboutSeptic Pumping Slip - 29 Granville Ln - 10/29/2024 - Septic Pumping Slip - 29 GRANVILLE LANE 10/29/2024 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: back side rear Ct )right
6�F�)
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Locatio
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return . 0 MA
key, CityfTown State Zip Code
2. System Owner:
-N-a—m-a
'W,:0iWs—w-d"Re-rent from
MA
CftyCTown State Zip Code
--yo
Telephone Number
B. Pumping Record 2. Quantity Pumped:
1. Date of Pumping
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes 7 No If yes, was it cleaned? Yes ❑ No
5. Observed co clition of component pumped:
6. System Pumped By:
Dave Tine ...... Mass 1AA96E as s 1 A D3
Name Vehicle License Nu r
Bateson Enterprises, Inc.
Company
7. Lot, tion where contents were disposed:
G LS
Date
-Signature o�f -eceiving Facility(or attach facility receipt) date
t5form4.doc-11112 System Pumping Record-Page 1 of 1