HomeMy WebLinkAboutSeptic Pumping Slip - 190 Gray St - Septic Pumping Slip - 190 GRAY STREET 9/30/2024 Commonwealth of Massachusetts
City/Town of
i
r
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health, Other forms 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 Pumpincg Record must be submitted to
the local Board of Health or other approving authority within 14 days from -he pumping date in
accordance with 310 CMR 15.351,
MOUSE: ront ack side rear left right
A. Facility information � autLollvG; font back side rear left ' ii
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2. Sys , Owner:
1 rrrVVVarne
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Address (0 different from locallon)
MA
CIIyrTown Slate
_ Telephone Number
B. Pumping Record C�
1. Date of Pumping oat/$ ", " 2. quantity Pumped;
Gallons
3, Component: ❑ Cesspoot(s) eptic Tank ❑ Tight Tank g ❑ Grease Trap
❑ Other (describe),
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? es ❑ No
5, Observed condition of component primped;
6, System Pumped By:
Dave Tiney _Mass 1AA95E Mass 1AD31Z
Name Vehicle Lloense Number
Ba(eson Enterprises, Im.
Company
7 Location where contents were disposed:
GL3D
Signature of Haul Date
f
Signature of t�eceiving l acillty(or atSach facility eecelpl) Date
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