HomeMy WebLinkAbout- - Septic Pumping Slip - 141 STONECLEAVE ROAD 8/14/2026 Tow
Commonwealth of Massachusetts n of Noqhn aver
City/Town of
4 System Pumping Record SEA 202
Form 4
Health e appt�
DEP has provided this form for use by local Boards of Health. Other forms may be usedPbut`t�t ent
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 the pumping date in
accordance with 310 CMR 15,351 ---..__-_-----�-bck)ii-de
__.—__—._..__....---.--_-_._
HOUSE: frbr rear leftA. Facility Information BUILDING: frontsde rear left rIg C
Important:When DECK: under"
filling out forms 1. System Loca on,
an the computer, ( /
use only the tab
key to move your Address
cursor-do not
use the return MA _ _
key. City/Tvwn State -- - Zip Code
�
f\/' 2. System r;
,
—4�L--e
I
Name
[w:wn
Address(if different from location) ---
MA
Y Stat Zip Code
06
Telephone Number
B. Pumping Record
X0
1. Date of Pumping ----- 2. Quantity Pumped:
- ----
Oate y p Gallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of comnt pumped:
6, System Pumped By:
Dave TIney Mass 1AA95E Mass 1AD31Z
Name ,-� —_ - �- —v Vehicle License Nu ber �-
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt} Date
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