HomeMy WebLinkAboutSeptic Pumping Slip - 166 Duncan Dr - 11/22/24 - Septic Pumping Slip - 166 DUNCAN DRIVE 11/22/2024 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: front oa3c )side rear left 11
A. Facility Information BUILDING: front back side rear left qrt
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab K4 ()CLnc-!! ------—-----
key to move your Address
cursor-do not MA
use the return
key. City/Town State Zip Code
2, System Owner:
Name
Address(if different from location)
MA
zipCodj____—----
City/Town State
B. Pumping Record
1, Date of Pumping 2. Quantity Pumped:
-b ate _��_allons
3, Component: ❑ 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? ❑ Yes ❑ No
5. Observed condition of component Pumped:
6. System Pumped By:
Dave Tine y ------------- Mass 1AA95E /imass IAD31Z—,--,------.
Name Vehicle License Nurngi_z:���
-Bateson Enterprises, Inc.
Company
T L tion where contents were disposed.-
'C
LS
Signature of Hauler Date
Signatureof Receiving"Facility(or attach facility receipt) Date
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