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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 404 SUMMER STREET 4/29/2024 Commonwealth of Massachusetts CIL / I uwit of 2024 la Y NI V Y f�iLJi Y' Sr' B77�Pi��iQH S"f�B.Ni—" "�Hi �V 16V2 i t p �11 N a./i N NM s vv'V '✓H Form 4 DEP has provided this form for use by local Boards of Health. Othi'foft may be used, but the 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. A. Facility information _.._ Left/Right front of h.ouse, Left/. ight rear-of house, Left/Right side of house, Under E Important:When filling out forms 1. System Locatio Left/ Right side of building, Left/Right front of building, Left/Right rear of building, . on the computer, CL S J — use only the tab key to move your Ackress �/ cursor-do not �k�_ MA ` use the return _....._ _ — -- ©� ------• key. Cityrrown State Zip Code e-1) 2. Sy, tteemm 0 er: Name INGW Address(if different from location) MA . Cityfl ewn - - - S1Atr7 lip Colo Telephone Number B. Pumping Record � � 1. Hate of Pumping Date 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank Q Grease Trap ❑ Other (describe): —- — -— - — 4. Effluent Tee Filter present? _Yes Q No If yes, was it rlPaned? xyes ❑ No. 5. Observed condition of component pumped: r 6. System Pumped By: Dave Tined .-. ---_---_— Mass F5U1 Name Vehicle License umber Bateson Enterprises, Inc. Company 7. Lo ere contents were disposed: �SD _ Signature of Hau r Date SiginahnH of RHi:k:iviny FACiiity(or Att2c.h facility roccilpli nHlr, t5form4.doc• 11/12 System Pumping Record "Page 1 of 1