HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 146 DEER MEADOW ROAD 12/9/2024 Commonwealth of Massachusetts
q2 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: (Znl ront� rlg�
1'* rich
)ack side rear le
A. Facility information BUILDING: t back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab —14co 5ea-- N<)dw-V
key to move your dr ss
cursor-do not
use the return r, -MA
key. City/*rown State Zip Code
2. System Owner:
-�arne -------
Address(if�different from—location) - -._
MA
City[Town State Tip-Co—de
`f-etephone umber
B. Pumping Record
/570
1, Date of Pumping 2. Quantity Pumped'.
-Nate Gallons
3. Component: F7 Cesspool(s) F71 Septic Tank ❑ Tight Tank El Grease Trap
[] Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? r7j1 Yes [] No
5. Observed condition of component pumped:
6, System Pumped By:
_gave jiney Mass 1AA95E e-lVf2ss 1AD'31-Z,
Name Vehicle License Numbe
Batescri Enterprises, Inc.
Company
T ion where contents were disposed:
G nL� D
-Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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