HomeMy WebLinkAboutSeptic Pumping Slip - 115 Olympic Ln - 11/12/2024 - Septic Pumping Slip - 115 OLYMPIC LANE 11/12/2024 C[]nim[}[\wea|th of Massachusetts
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System Pumping Record
Form 4
DEP has provided this form for use by |0os| Boards of H88|1h Other forms may be used but the
information must be oubatanUoUy the same as thoL provided here 2afore using this form` check with your
)OCa( Board Of Health to determine the 0J[m they use, The System Pumping Record must besubmitted to
the local Board Of Health or other approving authority within 14 days hopn the pumping date in
accordance with 310C&1R 15,351, -
HOUSE: front' back side rear(I�t�>jght
A. Fac'|'fv |MfOrmat'(}U BUILDING: front---- back side rear left right
|mport DECK: under
on�� m0eo �
filling out forms 1 SyabamLocation,
nn the computer,
use only the tab ` ~~
xeym move your Address
cu/so,-un not
MA
use the return
key, city/Town, State Zip Code
2, System
W/U11— ew
I I I I=J'N��
k8A
tale 1 Code
I one Number
B. Pumping Record
1 Date ofPumping 2, Quantity Pumped:
1 Component Cesepoo|(s) Septic Tank Tight Tank Grease Trap
Other (describe):
4. Effluent Tee Filter present? 0 Yes No If yes, was it cleaned? Yoe No
5, Observed condition of component pumped:
8 System Pumped d B
ys m V pe y:
Dave Tlney
wmmo Vehicle License wumher
.Bate.Bateson EnteEp Lls Inc
Cornpany
7� 31i,.on where contents were disposed:
ignature of Hauler Date
f ility(or attach facility receipt) Date
t5fmmn4dcc- 11U2 Systern Pumping Record ^ Page I of 1
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