HomeMy WebLinkAboutSeptic Pumping Slip - 76 Granville Lane 9.10.2024 - Septic Pumping Slip - 76 GRANVILLE LANE 9/10/2024 C-/ommonwealth of Massachusetts
T
0 C,�.y/ . own of
System Pumping Record
Form 4
r
DEP has provided this fQ,rM fo u5e by local BQald3 of HQalth. Other fQrm5 may be ubed, but the
information mi ust be subs"an' ;Iiv s2r—ne �,,g
l 1, the that providpd, here. Before using this form, check wlih your
local Board of Health to determine the form they use The System Pumping Record must be submitted to
the local Board of Health Qr other approv no alltnorjf
!,,V wilhin 11 4 clays from the pumping date in
accordance with 310 CMR I 5.351.
HOUSE: fron I side/'rea?x left' right
ion BUILDING: '(5 side��. l left right
A. Facility Information fron,
mportanf:When D E K. under
ffllng out forms I System Location:
on the comouie,,
use only In
tab A �irl
key to inove your Addr
cursor -jo no(.-,5e One retum MA- 0 1 K k_V57-
Ci i y�`r o w n State
,,ey, Zip Code
1 2, System Owner
Name
Address (if different from location'
MA
Cltyffown State,, Zip Code
elelonone Number
B. Pumping Record
Date of Pumping
Cale 2. Quantity Pumped. Gallons
3, '1--o mp o n e n t: --asspool(s) Septic Tank ❑ Tight Tank F-1 Grease Trap
❑ Other (describe),
4, Effluent Tee Filter rresent? E-1 Yes No f ves, was it cleaned? El Yes ❑ No
5 Observed condition of component pumped:
6, Svstem PjmQed 3v
Dave"Inev Mass 1AA95E —Mass
ass A D 3 I Z
Name icle Lice umber
)aiezon
—_
�,.n te rj:) IseS
Comioany
7 ion WJ,,.p,re conte its were Dispose:.
GLSD
Signature of Hauler Udte
_Signa-we of Receiving�Faciity�(oratAachfa,�ih receipt) Gate
System Pumping Reccord ,Paae 1 o.