HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 12 BARCO LANE 12/18/2025 uW� Commonwealth of Massachusetts
City/Town of
System Pumping Record
Forrn 4
DEP has provided this f`orrn for use by kcal Boards of Health, Other forms may be used, but the
inforrnatlon must be; substantially the sarne, as that provided here. Before using (his forrn, check will) your
local Board of Health to determine they frcrrrn they use; "I he, System f=ur'nping Record must be Submitted to
the local Board of I-Ic-;alth or other approviog authority vvllhin 14 days from the IDurnping data In
accordance with 310 C;MP, '15 3 1 ___._ tlCrClSf_: -front tack side rear "ht
A. Facility Information BUILDING 6t ruck side rear
important: Wlterr
DECK: urlde1,
(Ming out(t7rrns 1 SySt t��l(�fl:
On!lift only
tho u(er' ,✓�� �,MCf � s
use r>nfy fir tab 6 _.--- ..-....__ . _._.__.......
koy to move your Addross
cursor -do nal _..._. ,�f I/N& My
ta
key cityrrown State Zip Code,
(fk 2 stem Owner.
`F
-' Address (if different from location)
IV}A
Gity(1-own 5la _-
ip Cody
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B. Pumping Record
_ _ _ __
1. Date of Pumping .- - ?_. Quantity F'umpFud: _..___
)a(e (@Hons
3 Cornponent (__-) Ce sspooi(s) Peptic 'Tank
(_� (-fight Tank [_� Grease Trap
f _] y ` C
4. Effluent Tee Filter vrr �se.�nt?� Yr:s ( No If yes, was it c,learle,d" ] 1'c,s
:> Observed condition o •err lluonent fn nherd
,
6. S pt,e'r7f;;1,�mped By
Dave I loey _. .._ _._. Maass AA9 E Mass 1 AD317_
rrlSarr.1e A/c�hfcl l.irrnst Nurr�it.»r
Bateson'Enterprises_.Inc.
--
i pany
l l_oc (ion vvhere cot is were dispo,?ed
_.....
arCnakiro of f-i'aule( Date
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>'ic�rrtYlrrrE c7f f,r.t�a_Iwtirr� f ,+c'�Ilry (cif adtta<,t) fstc.iliCy
t`iformA.doc- 11112 System P irnpinp Record