HomeMy WebLinkAboutSeptic Pumping Slip - 70 Lost Pond Rd - 10/28/2024 - Septic Pumping Slip - 70 LOST POND LANE 10/28/2024 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 CIVIR 15.351.
HOUSE: f ro n K"bat yde rear left
A. Facility Information BUILDING: front "ba`dl� side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, -k-
,) (
use only the tab
key to move your Address
cursor-do not
75
use the return MA
key. City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
MA
_dit_)i(_f0_Wn State Zip Code
J 2
2,
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: 7 Cesspool(s) Septic Tank 7 Tight Tank 7 Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? ❑ Yes 7 No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tl Tine Mass 1AA95&� Mass 1AD 1Z_�
Name Vehicle License
Bateson Enterprises, Inc.
Company
7. L, ,ion where contents were disposed:
GL.SD
Signature of Hauler Date
Signature'jf Receiving'Facility-(or attach facility receipt) -rvDate
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