HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 99 RALEIGH TAVERN LANE 3/31/2025 Commonwealth of Massachusetts nO
z or
u City/Mown of � r
System Pumping Record Ap '22
Form 4 0Z
DEP has provided this form for use by local Boards of Health, Other" is be used, but the
information must be substantially the same as that provided here. Before usi IRPItyps ch ck with your
local Board of Health to determine the form they use, The System Purnping Record muMI submitted to
the local Board of Health or other approving authority within 14 days from *,he pumping date in
accordance with 310 GMft 15.351
HOUSE: fro ack side rear @, rip
A Facility Infornlatiorl SUVLDING: front hack side rear left DECK: under rigi-
I'
Important:When _
IIIIIng out forms 1. s stern oCatlon.
i on the computer,
use only the lab Jej__ OP p \ Zme
i key to move your dd ss 1
cursor -do out
f use the return _ _ -----__ _.. _.... -- —.._ MA ----.-...___ .__.— -
key, CVIyfrown skate Zip Code
2. Sy r7lOwner:
Ivy
,darn
Address (if different from location)
MA
C6Iy/fown _._..,__.. _ . ...-_ Seale
ZI Code
�
Telephone umber
B. Pumping Record �1
1. Date of Purnping 0a e ____ Quantity f umped'.
Gallons
s
3. Component _ Se[_] cesspool(s) ptic Tank ❑ Ti t-It Tank g ❑ Grease Trap
(� O1her (describe) ___.__ _ _--
4, Effluent Tee Filter present? [ ) Yes No If yes, was it cleaned? E] Yes No
5. Observed condition of componenl pumped:
I
u
5. system PL,mped By
Dave Tiney Mass 1AA95E Mass 1AD31Z
Name vehicle License Number
Bafeson Enterprises, Inc.
ramp any
T Location where contents were disposed:
GLSD
Signature of t1a ler - coin —- -
oiyrtalure of de;(,e iv rrq r ,arilily (or fnr„ility receipt) Otte
i
l5lorm4.doc- 11112 System Pumping Recor<f - Page 1 of 1