HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 167 HAY MEADOW ROAD 4/23/2025 Commonwealth of Massachusetts
G� ndaver
City/Town of
stern Pumping A�' '
r
Record
c o r c� 2 8 2025
y Form 4
DEP has provided this form for use by local Boards of Health, other forma � ,��jja of the
nforrnalion r-u.lst he sr.bstanlially the sarne as lhat provided here. Before, sing (his tb heck with your
Vocal Board of Heath to deterr�nine; the form they use. The Systern Pumping Record must be submitted to
the local Board of Health or ollher approvinc authority within 14 days iron) 'he purr)ping date in
accordance with 310 C M R 15.351,
HOUSE: from` ack side rea left krif;
A. Facility Informatior1 BUILDING: on back side rear le s
Important: When
DECK: under
(Ming oul forms 1 Syst4rn t oc",a ion.
oo the corn uler, t�
use only the
tab
key to move your luddrrasv
Cursor -do not
use (he retu n -- _ MAIj
— --- ---- = - ----
key Chyrrown" slate Zip code
2 S stern ownerName
kl� fAJ�
reurn
r ,
aratl Addr ..._._I( defi�a.....r,_ci_.r7_ l�rcrr.rt....._ .'c>_--.n).. _,_ ..._._ .....-...._ .,.__........_ ......._-_ .....�_........ ____ ._... _. _...__..._ ._._....-..,-__.___.�......____.._.._._......_.
ess (I f d
MA
G ly owrr >IaIH II Godr
_.__ __ ___...._
elephone Number
B, Purnpirig Record
_ t_c � ab�-
1. Date of aar ping ? Quantity F u m p e d:
Gallons
3. Cornponent: (� C essWoal(s) Septic
.lar,K ( ) Tight Tank ❑ Grease Trap
Other (describe) -...._ .___. .___.__ ---.---_ _-
4 Effluent Tee Filter present? (.-..) Yes ( .... No If yes, was it cleaned? D Yes [ No
5, Observed condi(ion of c;ornponef I�t,lrnfX2d_
_ - �_ ___._ - ._ _ .. ---------
5. `,ystern Pt,1r'nped By
Dive I_in y - Mess 1AA95E, "'_'Mass 1AD31Z
Varrre Vehicle LIcE�nse rVr.
Bafeson Enterprises, Inc.
- . .___.. --
l ri where
company
, contents were disposed
CSl v(
_..
Siclnelu�ta t>f Hauler [,aalc. --
Sldi7nUue of Ftecelving Teacllity tar attach (acility receipt) Date
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