HomeMy WebLinkAboutSeptic Pumping Slip - 175 Old Cart 9.24.2024 - Septic Pumping Slip - 175 OLD CART WAY 9/24/2024 1 , C1'ty1To vn of
System Pumping Record
A IrJ
Form 4
DIEP has provided this form for use by iocal tuards of `ealth, t�or f Or1S may b8 USED, but she
information must De substantially the Sane as that pio.F,ued here. `-afore using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local. Board of Health or other approving authority within 14 oayS from -he pumping date in
accordance with 310 `—MR —
__ _ HOUSE: front back side rear lei* right
8 D ^�
A. Facility Information Ui_ G: front back side rear left right
Important:when DECK. under
failing out forms ?. System Location.�`
on the Comoute'.
tie4;o Move y�JU` Address
cu(50" -,Jo col �s �-..3 i,i`� - r .h — t. 1
use the retu-n - --- -- - --
Ityt i own Stale Zip code
�eY-
'I 2. System Owner.
name
t � II
ffltYR '
Address (if different from location)
MA
Cily/Town Slate Zip Code
S1 t
Telephone Number
B. Pumping Record
Date of Pumping Date � — 2. Quantity oumped: Gallons
Component. L---� Cesspoous Septic Tank ❑ Tight Tank ,_ Grease Trap
[i Other ,describe;: — — -
4. effluent Tee Filter present? 0 Yes No If yes was it ciea"ted? — `es � No
~v=:.s e;Jed C u n C-' jo n4 :.rn p o n e nt ,_u . p e d.
v. System Pumped By
Gave Ti Mass IAA95E Mass !AD
Name Vehicle Ueense Nu er
Bateson Enterprises, Inc.
Company
tion where contents were disposed:
L5D
Signature o, Hader ate
Signature of Receiving facility (or attach facility receipt] -- Gate -----
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