HomeMy WebLinkAboutSeptic Pumping Slip - 75 Hay Meadow - 11/14/24 - Septic Pumping Slip - 75 HAY MEADOW ROAD 11/14/2024 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: ( roni� back side rear(Le?)right
t
ro
A. Facility Information BUILDING: roni' back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab
Address
key to move your ia7
cursor-do not MA o I
use the return _i�
key. City/Town State Zip ode
2. System Owner:
Name
Address(if different from location)
MA
Cityrrown State Zip Code
C
Telephone Number
B. Pumping Record
L
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: 7 Cesspool(s) Septic Tank 7 Tight Tank ❑ Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? F Yes ❑ No
5. Observed condition of component pumped:
-----------
6, System Pumped By:
_Pave Tine Ma§e,-A mass 1 AD31 Z
Name Velt license ber
Bateson EnttrLrises,Inc.
Company
7. ion where contents were disposed:
GLS
Signature of Hauler Date ❑
Signature of Rece_ivinglFac7Ir-
Ity(or attach fac
ility receipt) Date
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