HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 488 SHARPNERS POND ROAD 12/10/2024 Commonwealth of Massachusetts
u =u� City/Town of
ffi System
yst 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 .he pumping date in
accordance with 310 CMR 15 351.
HOUSE front back side rear `left right
A. Facility information BUILDING: front back side `ream left right
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key. Cilyffown 5la(e Lip Code
2. Syste O ner.
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Address (if different from loc;aliw)
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Lip Code
Telephone Number
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B. Pumping Record
1, Date of Pumping _.._..._.----___-- 2, Quantity Pumped
Gate Gallons
3. Component. �_� Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
[_) Other (describe) -...._ ____..... _..___ __.____
4, Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E Mass 1AD3,IZ
fdanie Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed
GLSD
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Signature of Hau er Date
Slctnalure Of Receiving F acility (or attach fsacili(y receipt) Date
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