HomeMy WebLinkAboutSeptic Pumping Slip - 209 Bridges Ln - 11/20/2024 - Septic Pumping Slip - 209 BRIDGES LANE 11/20/2024 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.
7-- left HOUSE: front' back)side rear le (right
A. Facility Information BUILDING: front"'6�6k side rear left rig"'h't'
Important:When DECK: under
filling out forms 1. System Location:
on the computer.
use only the tab
key to move your Address
cursor-do not g. MA
use the return 0
key. City[Town State Zip Code
2. System Owner:
Name
Address(if different from location)
MA
City[Town State Zip Code
Telephone Number
B. Pumping Record
8 d P Quantity Pumped:1. Date of Pumping —bate 2. Quan
- Gallons
3. Component: M Cesspool(s) Septic Tank 7 Tight Tank 7 Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? Yes F] No If yes, was it cleaned? Yes D No
5. Observed condition of component pumped:
6. System Pumped By:
_Pave Mass 1AA95E /Mass 1AD31Z'N
Name Vehicle License Numbe'r-1
Bateson Enterprises, Inc.
_66m_p_a_ny'
7. 'ocat'n where contents were disposed:
G L S3:D;" vv'
Signature of RauiW_ Date
_Signature of Receiving Facility(or attach facility receipt) Date
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