HomeMy WebLinkAboutSeptic Pumping Slip 09.24.2024 - Septic Pumping Slip - 31 VEST WAY 9/24/2024 Uommonwealth of Massachuset"T
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System Pumping Record
Form 4
DEP has provided 'his form for use by loca! Boards of Health. Other forms may be used, but the
information must be substantially the same as that pl'ov�ded here. Before using this form, check, with your
local Board of Health t0 determine the form they use. The System Pumping Record must be submiMed to
the local Board of Health or other approving authority within 14 days from -he pumping date In
accordance with �-10 C M R !I 5.3�1 H 0 U S E: front back "iide rear 6? r i 6 h,
A. Facility Information B U111 L D 1 N G front back side rear left rich:
Important:When DECK: under
filling out forms 1 System Loqatlon:
on the computer,
ndy 1 6 ta� L'0��4
key to mo your Adpr6ss
Cursor -do n0i im - A��_6t f MA S,
use the return City own State Zip Code
key.
2. System Owner
Oc'n 0 v
Name
llwwn
Address (if different from location)
MA
Clly/Town State Zip Code
�C_�S,---- _ q L
Telephone Number
B. Pumping Record
ij a--t"l v u;roped e d Date of Pumping I Date Gallons
.3. Component: ❑ Cesspool(s, Grease Trap
Septic Tank Tight Tank L-i
❑
Other (describe,
4 Effluent Tee Filter present? Yes No if yes, was It cleaned? ED Yes No
5. Observed condition of cornloonent p,,Iimlpeo:
& System Pumped By
Dave Tiney Mass 'j?kA.95 Mass AD-j'l el j
Mass Mass=7
Name Vehicle License NI r
__'a'es,n E r-n1eI-rise--, 1 nl
Company
7 Cn where contents were disposed
)
W, 12q
Signature of I-l'-Uielf Date
Slgriwuna of
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