HomeMy WebLinkAboutSeptic Pumping Slip - 59 Sunset Rock Rd - 10/24/2024 - Septic Pumping Slip - 59 SUNSET ROCK ROAD 10/24/2024 5L 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: front ack side rear left right
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 E�t '5U"oc1V
key to move your Address
cursor-do not k) L, MA
use the return
key. City[Town State Zip Code
2. Syst9m Owner:
Name
Address(if different from location)
MA
City/Town State Zip Code
C
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: 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 111 No If yes, was it cleaned? ❑ Yes 7 No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney. Mass 1AA95E z--,vl ss IAD5 z
Name Vehicle License Nu(zbe—r
Bateson Enterprises, Inc.
Company
7. ocptii n where contents were disposed:
at GILS
Signature of Hauler Date
Signature of Receiving'Facility(or attach facility receipt) Date
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