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HomeMy WebLinkAboutSeptic Pumping Sliip - 2189 Turnpike St - Septic Pumping Slip - 2189 TURNPIKE STREET 9/19/2024 i Commonwealth of Massachusetts City/Town of ,I System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, bttt the information must be substantially the same as that provided here, Before using [his form, check with your local Board of Health to determine the form [hey 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. HOUS[, front back side rear left right A. FacilityInformation BUIit�IN^ G: ` :Oorn)t back side rear left right t3 Important;When DECK, under filling out forms 1. System Location; on the computer, use only the lab key to move your Address cursor -do not _MA l�j use the velum MA ITown _ - key, y Stale Zip Code 1,0 2, System Owner: 60 Name Address (11 difierenl from location) MA Cily(rown Slate Zlp Code Telephone Number B, Pumping Record 1. ©ate of humping 2. Quantity Pumped: Dale p Galfons 3. Component: ❑ Cesspooi(s) Septic Tank ❑ Ti ht Tank 9 ❑ Grease Trap ❑ Other (describe): � . 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cieaned? ❑ Yes ❑ No 5. Observed condition of component pumped; Po 1 6. Syslern PyrnPp d By: Dave Tiney Mass 1AA9 Mass 1AD311 Name Ti e+ cense Number t3eteson Enter.p6ses, Inc company 7. 'on where contents were disposed: GLS _ SignaturAof aufer Dale Signature of Receivin FFac'ill(y(or abaci) faclMy rewlpl) Date l5formUoc' 11112 System Pumping Record-Page 1 of 1