HomeMy WebLinkAboutSeptic Pumping Slip - 116 Christian Way - Septic Pumping Slip - 116 CHRISTIAN WAY 9/16/2024 se+�s
Commonwealth o" Massac% Li
Pli-�' i19 Citv/Town of
AV` System Pumping Record
Form 4
DEP has Provided this fora 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
locai Board of Health to determine the form rtey use, The System Pumping Record must be submitted to
the local Board of Health or othel, approvi, o authority witNn 14 days from -.he pumping date in
accordance with 3 10 CMR 15 35l
H 0,LJ S E: front back side r left right
A. Facility Information QSLJILDING: front back side rear left right
rnpor-tant:iNhen DECK: under
filling out forms System
on the computer,
use ondy the tab fi, ( 4j�L,
tray to move you., ka d Nrg s
cursor-do not MA
use the return
kev. Ulty/Town State Zip Code
2. System Owner,
j A
"L
ame J
Address (if different from location)
MA
C ity own V---
/T1 State �P1—_ - 'ip Code
State
Telephone elephone Number
B. Pumping Record
1 Date of Pumping Quantity Pumped'.- Da`e Gallons
3. Component: ❑ Cesspool(s) 17— Septic Tank ❑ Tight Tank ❑ Grease Trap
I I Other 1c iU escribe),
yes, was it cleaned? F7 Yes L7. No
4. Effluent Tee Filter present? Yes tel.-I�o
5. Observed condition of comconent pum ed:
.A-160
6. System Pumped By
Dave Tiney Mass 1AA95--E I 1 ass s s 1 A D"3 ZZ
Nose License N ber
Ei2teS0 l--ntC-rrjrises, In
Company
LOC�. �here contents were disPosed:
(C,L 5 D
,5 F_)
S: of'_l'ui�'
iqnatu�e of Hauler Date
-S-1pat�eof ire—,dngg�-Fa, Date
l5form4.doc- 11112 System Pumping Record Page 1 of 1