HomeMy WebLinkAboutSeptic Pumping Slip - 120 Liberty - Septic Pumping Slip - 120 LIBERTY STREET 9/25/2024 Commonwealth of Massachusetts
City/Town of
r
System Pumping Record
k 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 Pumping 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, —
__ HOU7;E: Eton back side rear eft right
A. Facility information BUILDING: r-ont back side rear left right
Important:when DECK: under
slung out forms 1. System I-ocatlo ;
on{toe only
the t or, !� p {} �
use only the lab ! l- 17
key to move your Addross -
cursor • o not n ��«� f�
use iha reeturn MA
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key, CIIy/Town Stale ZIP Code
2. System Owner:
e td
1
gran
Addmss (if differant from location)
MA
Cily(rown Sla(e Zlp Code
Telephone Numbar
B. Pumping Record
1, Date of Pumping dale` I 2. Quantity Pumped, —'
Gallons
3. Componen(, ❑ Cesspool(s) Septic Tank ❑ Tight Tank Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed con ition of component pumped:
6. System P>!m.ped By:
Dave piney Mass 1AA95E Mass 1AD
Name Vohicle Lleense Nu bet
Meson Enlerprises, Inc.
Company ___u`W
7, on where contents were disposed:
GLSb
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Signaluro o{Hauler Dalo
Slgnalure of Receiving a( tufty (or attach iacility eecelpl) Dale
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