HomeMy WebLinkAboutSeptic Pumping Slip - 197 Vest Way - 10/31/24 - Septic Pumping Slip - 197 VEST WAY 10/31/2024 Commonwealth of Massachusetts
c pity/Town of
' .° System Pumping Record
1
Farri-I 4
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 that provided here, Before 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 days from -he pumping date in
accordance with 310 CMR 15 351
HOUSE :Zi, .hack side rear left right
A. Facility Information BUILDING. front back side rear left right
Important: When
DECK: under
C,n lhe, ut f aver, /Sm Locationh
usle oroly theta
key to move your Address q
cursor-do not �/� MA
use the return __ "b ___ . ..
key City/town Ste(e Zip Code
2— S%steim 01Nfl (:
1 ___-1
..__.__. N d f r1 e ........
aewn
Address (lf differer7t from locafiorr)
MA
CRylTown State
r LI ode
Telephone N tuber
.._._......
B. Purnping Record6N
1. Date of Pumping o- _ 2. Quantity Pumped.
Gallons
3. Component: ❑ Cesspool(s) �epticnk ❑ Tight Tank ❑ Grease Trap
Other (describe): —._.__. . ____._-_ __._._..__..__.._—_
4, E ffla.lerlt Tee Filter present? [� Yes No If yes, was it cleaned? El Yes (� No
5. Observed condition of component pumped
5 System Pumped By
Mass 1 AA`i15E Mass 1 AD31 Z Cave T(n�:Y. _. _ __. __ ._..._._
Name Vehicle License Nurnher
Bareson Enterprises, Inc.
Company
7. Location where Contents were dispersed.
GLSU
Signature of Hauler Date
Signature of Receiving raclllty (or a aclr facility receipt) Gate
i5lorm4.doc- 11112 ;ystern Purnpiog Record Page 1 of 1