HomeMy WebLinkAboutSeptic Pumping Slip - 55 Stonecleave Rd - 11/21/2024 - Septic Pumping Slip - 55 STONECLEAVE ROAD 11/21/2024 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 CMR 16.351. ----
HOUSE: ont� back side rear le� rig
A. Facility Information BUILDING: rout back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab s4Vned'e CA-UC q L --------
key to move your Address
cursor-do not h,j , n 6 LA- MA
use the return
key. City[Town State Zip Code
2. System Owner:
1-k C e- �C' C\1-4
Name
�❑_.__ � �.�_._--�.�____________._,_.�__.❑��_____.<__
Address(if different from location)
MA
Cit—yfTown State
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Gallons
3. Component: F7 Cesspool(s) Septic Tank ❑ Tight Tank 71 Grease Trap
F-1 Other (describe):
4. Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? ❑ Yes 0 No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E Mls-�sl AD 3 1
Name Vehicle License Numbk
Bateson Enterprises, inc.
Company
7. ion where contents were disposed:
GLS
6(-- bi-te � ❑
Signature of Hauler
-Signature of Receiving Facility(or attach facility receipt) v Date
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