HomeMy WebLinkAboutSeptic Pumping Slip 9.20.2024 - Septic Pumping Slip - 35 ROCKY BROOK ROAD 9/20/2024 t
U o m m o n a 1 t h o)1 Ma s,s aic h rs,41 s e',,
gf 16, C*ty/—own of
System Pumping Record
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Form 4
DEP has provided l]n S fora, for use f-v 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
i
iocal Board of Health to determine the form tney use. T he System Frumpino Record must be submitted to
the local Board of Health or other approving authority within 1I days from -.he pumping date in
accordance with 3 10 CMR 15.3 51. HOUSE: front back side)ear left' nigh.
C
A. Facility Information BUiLDING: front back sae rear left right
Important:When DECK: under
Hiling ou,forms System Location,
the computer,
use only the' ta'b R
Rev to move voui Ars
cursor -do not
use the return MA C)
kev. Cilyffown Slate Zip Code
System Owner
Y "C C_ iC,
Name
rl
Address (if different from location;
M A
a t_Y[T Zip Code
i eiephone Number
B, Pumping Record
If Date of Pumping C( 2. Quantity Pumped� is-Of-
Date Gallons
s. Component: L® Cesspool(s; Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other {descri,De}.
4. Effluent Tee Filter present? 0 Yes No if yes, was it cleaned? El Yes v No
n 5, Observed Condition of componel pun red:
--tAx
6, System, Pumped' By.
E�M�111�D�3'1
-ave -ney Mass 'AA951_- Mass 1A1UP_
D
Name Vehicle License N
B2'eson Enlefpf!Se,, inc.
Company
t on where contents were disposed
GIL 5 L D
Signature of Hauler Date
Sig e of Re-,v1nqq 1,y(of attachfaciiily receipt) Date
l5form4,doc, 11112 Systern Pumping Record Page 1 of l