HomeMy WebLinkAboutSeptic Pumping Slip - 547 Winter St - 9.20.2024 - Septic Pumping Slip - 547 WINTER STREET 9/20/2024 Uommonvvealvh of Massachus;--tts
Co City/7 own of
6V System Pumping Record
U V
Form
DEP has provided this form for use by local Boards of Health, Other forms may be used, but the
information must be substantially the same as ;hat provided here. before using this form, check with your
kcal Board of Health to determine the form the
y use. The System Pumping Record must be submitted to
the local Boar d of Health or other 9P.Proving authority within 14 days from -.he pumping d2te in
accordance with 3 10 CM R 351,
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HOUSE 0fron back side reac" left l righ
r-
A. acility Informatiort BUILDINGi ront back side rear left right
Important;When DE:C K: under
filling out forms 11, System Locatio
on the computer,
use only Me tab
key to move yQui Address
cursof -do not
MA
use the return
Al-An-
return
key City[Town State Z=p Code
2. Systern Owner
V,
;yam a
Address (if different from locat'on)
MA
cilyf`own stale Zip Code
Telephone Number
B. Pumping Record
Date of Pumping A52( IQU2ntity Pumped�
Date Gallons
3, Component LJ .essQool(s) Septic Tank ❑ Tight Tank Ej Grease T rap
I
❑
Other (describe)
4. Effluent Tee Filter present? ❑ Yes No if Yes, WEIS it cleaned? ❑ Yes ❑ No
Observed Bondi on of component pumped:
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6, System Pumped By
Dave Tiney Mass�'IAA95E' �Ma s s�!A D 3
Name Vehicle License N ber
Bates,,n DnScS'
Company
7, ��hon where contents were disposed:
,Ldn
Signature of Haute: Date
Date
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