HomeMy WebLinkAboutSeptic Pumping Slip - 284 Summer St - 10/31/24 - Septic Pumping Slip - 284 SUMMER STREET 10/31/2024 Commonwealth of Massachusetts
C I'ty/Town of
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, W the
Information MUSt be substantially the same, as that provided here. Before using ihis form, check with your
local Board of Health to determine the form they use, The System Pumping Record must be submik ed to
the local Board of Health or other approving authority within 14 days from ,he pumping date in
accordance with 310 OMR 15351.
HOUSE,,,�,front Eck side rear left right
L t A. Facility Information BUILDING, front back side rear left right
Important: When DECK: under
oiling out forms I Systern Locatioi
or)the cornputet,
use only the tab
key to move your d re ss
cursor -do not MA
use the return .1 Ic
key, c iy rows Slate Zip Code
2. Systern Owner:
I
14 1 d e ....... -------
-T�
Na
Ad dross (If different from location)
MA
CIIylrowra Slate
Telephone Number
B. Pumping Record
1 Date of PUr apt ng Date 2 Quantity Pumped. Gallons ----------
3. Component', Cesspool(s) � Septic lank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4 Effluent 'Tee Filter present? E] Yes if yes, was it cleaned? ❑ Yes No
5. Observed condition of con-i[Donent purnped�
.......... ----------------_---
6. Systerri Purnped By
Dave 1-iney__ Mass IAA95E Mass IAD31Z
....................
Name Vehicle License Number
B2teson Enter�)rlsp.s, Inc.
company
7. Location where contents were disposed:
GLSD
Signature of Hauler D a I.e
............
signature of Receiving Facility (or attach facility receipt) Date
t5lo(m4.doc- 11112
System Punniping Record - Page 1 of 1