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HomeMy WebLinkAboutSeptic Pumping Slip - 4 Christian - Septic Pumping Slip - 4 CHRISTIAN WAY 10/2/2024 Commonweall[I 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 used, bUl the information must be substantially the same as that provided i)oro. Before using this form, chocl<wilh your local Board of Health to determine the form they use, The System Pumping Record must be submftted to the local Board of Health or other approving aulhority within 14 days from the pumping dale in accordance with 310 CMR 15.351, HOUSE: ron bath side rear eft, right A. Facility Information BUILDING: Front back side rearTeft right Important;Whan DECK; under { IfFing out forms 1. Syslern ocat'on; on the compulor, , y use onfy Iha lab C rl5 key;o move your Addrass cursor •do no( S use the return �n`� MA Z ke cllyfyown y. Slate u 7 p ode ra 2. System Owner: Name Address (If diHerdnt fsam lo.calionj �" - --�.—_. MA CIEylTown - Slat© Zip Code Telepl�onc Numbar t3, Pumping Record 1. Date of Pumping �a€16fi2 r? 2. Quantity Pum ed'. e y Gallons 3. Component: ❑ Cesspool(s) � Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ O#her (describe); 4. Effluent Tee Fiiler present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component purnped; 6. System Pumped By: Dave Tine ^__ ass 1AD Mass 1AA95F 31Z Name Vehicle LlCense (dumber `-- Bateson Enterp(ises, lhc. Company _ _ — l. lion where contents were disposed, GLS Signature of Hauler Dale Signature or RaGaiving'raciilly (or•ahach facility receipt) pate —" �---- 151ormrt,doc• ttfl2 Sys lem Pumping Record Pace i of t