HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 109 RALEIGH TAVERN LANE 12/10/2024 Commonwealth of Massachusetts
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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 ae 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 31OCMR 15,351 -
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A. Facility Information BUILDING: front —back--� side rear left right
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Important; DECK:�n����eo
filling out forms 1. System Location:
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use only the tab
key to move your *u��us ��
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key. —`[To—n State Zip Code
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Address(if different from location)
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City[Town State _f, Code
-te—lephone Number
B. Pumping Record
1, Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: Cesspool(s) Septic Tank 7 Tight Tank Grease Trap
F] Other(describe):
4. Effluent Tee Filter present? [] Yes No If yes, was it cleaned? Fl Yee No
5. Observed condition of component pumped:
O. System Pumped By:
Pave T|n
Name Veh
Bate Bateson E � Inc.
Company
7. 1 ion where contents were disposed:
LS
Signature of Hauler Date
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