HomeMy WebLinkAbout991 Johnson Street - Septic Pumping Slip 2024.09.13 - Septic Pumping Slip - 991 JOHNSON STREET 9/13/2024 0 M m o mf�ry-13 ka!It h a h u s e I t S
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System Pumping Recorc�
Form 4
DEP has Provided this form "oi- use 'hy local Boares of Heallh, C-0— for-Mv may be u3en, 4iul the
informahon nqust ie subst2nnally the sp-me n�-, rth2! provided hers. Rpfnore ugli)Q lhiS for im, check with Your
fee@! Board of Health to determine the folrm Mey use. The System Pumping Record must be sunmi;ted i o
the local Board of Health or other approving autholrihy W�
Ohl days 'rom rhe pumpino dale it
accordance with 310 CMR
J-
HOUSE-: front back side ear e
A. F a c; - (ED
ility information Rl ILDING fion, oack
6de rear
imporllan(:V016n u—,t C K u r,de,
filling out forms 1 System Locanon,
on the computer,
use only the iab
key to move your Address
--
cursor -do not
use the return MA
key, C-lyf—owr)
,!ale ZIT)Code
Si/slem Owner
Na m e
AUAddress M di{#ereni from location}
l A VI
-Clt�yffillll SI a t—e — Z!,—Cld,
B. Pumping Record
I Date of Pumping
-0-.��e 2� Quantity Pumped. Gallons—
s. Component: Cessnool(sl
Septic Tank
Tiahl Tank
i Grease 'rap
—Other " escrfbe,
j u
4 Effluent Tee Filter p.resent? I Yes �' N o If yes, was il r--` No
Li ciearled" Kl'es
Observed condition of corli'Donent purinpeci
6, System Pumped By
A A M a s s--A A D Z
S
_e as I AA9
Name Ze In fic 1 e Licen umber
Bateson Enterprises Inc.
Company
7, tion where contents were disposed
G L 5
Signature or Hauler Date
Signature o' ReCeiving r-acy facilioy 'gate
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151ofrn4.doc 11112 S-Yslem Punrromq ReCord Paujc- I