HomeMy WebLinkAboutSeptic Pumping Slip - 89 Lost Pond - Septic Pumping Slip - 89 LOST POND LANE 9/30/2024 Commonwea
lth of Massachusetts
T 10 City/Town of
r
System Pumping Record
Form Q
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, Refore using this form, check with your
local Board of Health to determine the form they use, The System Pumping Record must be subrnitted to
the local Board of Health or other approving authority within 14 days from ,he pumping date in
accordance with 310 OMR 15,351.
HOUSE: frontt ack side rear left- 5ht
A, Eaciiity Information BUILDING, "frZt t back side rear left right
Important:When DECK: under
fitgng oul forms 1. System Location:
on the computor,
use only the lab
Key to Move your Address
cursor-do not MA [�
use the return Cfl frown mm
toy. Y Slate ZIP code
2, System Owne
f, td
name
rrrwn
Address (It different from tocallon)
_ MA
CllyfTown Slate Zip Coda
Telephone Numb
B, Pumping Record
e
1. Date of Pumping 3b — 2. Quantity Pumped:
Date Gallons
3. Component: ❑ cesspool(s) Septic Tank ❑ Tight Tank g El Grease Trap
❑ Other (describe): -
1
4. Effluent Tee Filter present? ❑ Yes No if yes, was it cleaned? ❑ Yes ❑ No
I
5, Observed condition of component pumped;
6. System Pumped By:
Dave Tine __ Mass 1AA95 Mass D31Z
�__
Name Vehlcie L-Icense Nu
Meson Efiter rises, Inc.
company
7. (son where contents were disposed:
GLSp
Signature of Hauler Dale
Signature of Receiving Facility(or attach faclitty receipt) gate
151orm4,doc- 11112 Syslern Pumping Record •Page 1 of 1