HomeMy WebLinkAboutSeptic Pumping Slip - 20 N Cross Road 9.17.2024 - Septic Pumping Slip - 20 NORTH CROSS ROAD 9/17/2024 y/7 nwn of
System Pumping Record
Form
DEP has provided this form to, use Yy ocal Boaidis of Hicalth f Or M 5
may 0 e u 3 fd, r-,iji i 1,-
ro,vr�jpd rrn, lh i
in')OM-falion mus� be substanlkio me 2-
.y the s2s ih,-,i p
% I i here, POcire using 'h 9 t 1 1 fo check w 1, yo Uf
local Board of Health to deternne the form they use. The System Pumping Record must 4e supmi"e.d to
the local Board of Health or other appioviing, authority withln'14 days from the pump;
. ing date in
accordance wi 1,h 310 C M R 1 5,3-5 1
HOUSE: front back s ce rear r of;
A. Facility information B U 1 L D i N G front back 6cic fear lPff, ht
h-npOrlant:IlVher,, D E CK under
(filing out forms 1 System Location
on the compuref.
use only the lab 2-0110
key to move VOW Addrass
cursof -do not
use the tallum M/4
ka
v _0 LI
Sate Zip Code
2. Svslem Owner,
—LI I—AL t >
Name
Address of different from rocation}
MA
y own
,a t�e —
S; Z 1 P Code
'4umbe;
B. Pumping Record
I Date of Pumping a- 2. Quantity Pumped
Date Gallons
3. Component: El '—esspool(sl
Se.oft- Tank Tight Tans ❑ Grease Trap
E] Other (describe',
4. Effluent Tee Filter present? 1-0 Yes No if Yes, was it cieaned-%
e s N
5, Observed condition of componen! pumped"
6 System Pumped By
Dave
-,�AL�95E�N�Aass -,4�o3-iz
NaML L 1.
Bateson Enterprises, inc
Company
7 f on where contents were disposed
(G L S
Signature of Hauler Date
Facility'nr'atlach facility,eceipi` Date
Signature of Receiving
15I0fM4.d0CI I'MI-)
System Pumping RP.COrd Paqe