HomeMy WebLinkAboutSeptic Pumping Slip - 19 Boxford St 9.11.2024 - Septic Pumping Slip - 19 BOXFORD STREET 9/11/2024 Uommonwealth of Massalclhluse s
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;I SySteM Pumping Record
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�._� ,��.a, �, r:�s G{; �e�,?r:� ��!� `orms may be used, Sul 1w
ilnformation mius! Ole sit' Ct ho- t • L�he me th t nr 4� i 4 .,
p bd -d Oi'Id2 E ��f�rE USir F iS Grrnl, check t t V� .
local BOard f Health to determine the vrm er use. The S,ys'e`+'3 Pumping Record rust e subt i1 ed to
the loca) Board Vt Health or othef a tJ k 1 1.. t Udyv 1 i tl;� rnt 1
r, u, nU da: in
accordance With 3 ,0 CMR '6 ?51�
-- ----- H0 USE:: fro a ;i ? rear ie'
A. Facility Information R_ty LD1NG ;Q oar ft h
Impor-tant:VAAan "VC�iP_r ig i ru
(":ling cut ior.,,, SvSte=il ' GC fiO.n
on the compurif.
use only the,e,. �\J
key to move your A:-d.ssc_ — --
cursor -do not ,,, f
use the return � c _ _ MAi
Key, C{Iyr"Qwn Mate Zip Cede
—� C. System Ow netLA '102-
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b
m Name
l r.tern `r
Address (if dif`erent hom iocaFon; - —
_ M
Clfy�own � :
S,a;e 'Ip Cope
e':ephone Number
B, Pumping Record
Date of Pumping 2 Quantity Pumped
Gate Gallons
s. Component: Cess oci;s? TankQTight TankSep is —
i Grease Trap
Q Other (describer
a. Effiluent Tee Filter ;esA 1 �e v-c �s ��
p s ' ..as it c eanedt I Yes 10 No
5. Observed condition of component pumped
6 System Pumped By
Mass AA95 mass ll-
Name Vehicle t_icense umber --
Bateson, Enterorises, inc,
Company
a!iGi1 where contents were dispose:.
G L S
- CA
Signature -
Signature of Hauler Pate
Signature �{ Receiving '=aeillty (oratiaeh faeiliC receipt, "ate ---
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