HomeMy WebLinkAboutSeptic Pumping Slip -222 Bridges Lane 9.16.2024 - Septic Pumping Slip - 222 BRIDGES LANE 9/16/2024 se++
I L L
Commonwealth of N,"lassad us
t9 City/Town of
iFi System Pumping Record
Form 4
DEP has provided this for 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. T he System Pumping 'Record must be submitted to
the local Board of Health or other approvinG 2uthoril/ within 14
days from he pumping date in
accordance with 310 CMR 15,351, 1
HOUSE: front bacll sic rear left r 09 h I
A. Facility Information 81JILDING: front back-:sWe rear left right
important:When DECK: under
'1111rig out to'ms 1,� System Location
on the compute.,
use onit,the tab
key to move your -Sr
cursor-do not MA
use the return Aj__�_A_A1A) _ —
key Cityrrown State zt1p code
2. SvsLem Owner:
Name
Address (if differiont from location)
MA
City/T own State Zip Code
Telephone Number
B. Pumping Record
Date of Pumping DateGallons
z Quantity Pumped:
3. Component: ❑ Cesspool(s) Septic Tank 0 Tight Tank 0 Grease Trap
Other "describe"
4, Effluent Tee Filter present? [I Yes No If yes, was it cleaned? F—If Yes [] No
Observed condition of component pumped:
& System Pumped By.
Dave Tine} Mass 1AA95-E Mass 1AD--,1-'7
Name Vehicle License Number
L: erDriSeS,
Sa6-�,sor 'nf
cp�m_P-ly
7. Location where contents were disposed
C iLc�bD
signature of l;�Xe r Date
Signature of Recei4ing aril ty er attach ta,,nt�y Date
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