HomeMy WebLinkAboutSeptic Pumping Slip - 261 Rea St - 11/12/24 - Septic Pumping Slip - 261 REA STREET 11/12/2024 Commonwealth of Massachusetts
City/Town of
System Pumping Record
c4 = Form 4
:
DBP 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 OMR 15,351 _-_.--------.__.. - _._.__.. ._._..__. G
HOUSE fr
_.._ .___—._. o t;k side rear ri5ht
f� Facility information BUILDING: rantback side rear right
Important:When CHECK: unde1,
filling out forms 1. stf m Location:
on the cornpuler,
use only the tab
key to move your
cursor-do not MA
u
use the return _...-,., _ ___ .._ __— _—_.
key ;Ily/town - sla(e Lip Code
_ 2. S stern Owner:
—--� N a rn e -
Pj
latu'p +
Address (if different frorn location)
MR
GVIy/Town siate C
Telephone Number
__.___._...__.-....._---—_-__--------------._.._...__
B. Pumping Record
1. Date of Pura. in -
ta g ___ ___._.___ 1_ Quantity Pumped'.
Date G (Ions
3. Component: ❑ Cesspool(s) optic 'Tank ❑ 'Tight Tank g ❑ Grease Trap
Other (describe):
4 Effluent Tee Filter present? �._) YF';`+s z_�.. (I10 If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. Systetrt Pumped By
Dave TlneY.. __-- Mass 1AA,95E Mass 1AD31Z
Name Vehicle License Nr.rrr�trer
Bateson Enterprises, Inc,.
C
-om-. ---pany ---, —------ ----_ _-._
7 Location where contents were disposed
GL5D
.....-......_ .. .. - _. -----
Signature of Hauler Date
;Igr7ature of Receiving'Facility (or atiaci) facil((y rr,or,ipl) Date
t5form4.doc- 11112 System Pumping Record - Page 1 of 1