HomeMy WebLinkAboutSeptic Pumping Slip - 78 Lacy St - Septic Pumping Slip - 78 LACY STREET 9/27/2024 I
Commonwealth of Massachusetts
-� , City/Town of
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health, Other forms may be users, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Heafth to determine the form They use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 1 p days from .he purnping date in
accordance with 310 CMR 15,351.
HOUSE: front)back skle rearCleft ight
A. Facility Information — euluDMG; Iont back side rear left right
Important;When DECK: Under
filling oul forms 1. System L.ocatlom
on the computer, +
use only the lab
Key to move your Address
cursor •do no{ �� �, �• MA
..,.
use Iha return Cfl /Town �
key. Y 51aie Zip code
2, System Owner:
\(JrN
r�
� Name
nnrn
Address (Il differeni from looallon)
MA
cliy[Town _ State
>> (` _ Zip Code
3' ' t
Telephone Number
B, Pumping Record
Oc
1. Date of Pumping pale—�� 2. Quantity pumped.
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): _
4. Effluent Tee F'iitef present? ❑ Yes � No ff yes, was it GSeaned? ❑ Yes ❑ No
5. Observers condition of component pumped: J
6. Systerri Plamped By:
Dave 1•iney ^� Mass 1AA95 IGiass 1AD31Z
Name Vehicle t-lcense Nu er
Sateson Enterprise
Company
7. r It n where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Recelving Facility(or attach facility receipt) Date
151orm4.dOc 13112 5yslem Pumping Record-Page 1 of i