HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 98 FULLER ROAD 12/13/2024 'L 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 CM 15.351,
HOUSE: pfron6 back side rear le right
ro
A. Facility Information BUILDING: ront back side rear 4e right
Important:When DECK: under
filling out forms 1. System LoC ion:
on the computer, 11
use only the tab
%
key to move your Address
cursor-do not MA
use the return G
key. CityfTown State Zip Code
2. System Owner:
------------------
Name
Address(if different from location)
MA
City/Town State Zip Code
-Telephone Number
B. Pumping Record
1. Date of Pumping —Cj7a 2. Quantity Pumped-
G-a—tlons
3. Component: 7 Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? 7 Yes [] No
5. Observed conditio of component pumped:
Uz P
6, System Pumped By:
_Dave Mass 1AA95E - Kass IAD31Z)
Name Vehicle License Numb)5,c��
Bateson Enterprises, Inc.
Company
7. o tion where contents were disposed:
GLSD
/Z
Si nature of Hbuler Date
Signature f ReceivingI�y(o r attach facility rec-ej p't—) Date
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