HomeMy WebLinkAboutSeptic Pumping Slip - 784 Winter St - 11/13/2024 - Septic Pumping Slip - 784 WINTER STREET 11/13/2024 Commonwealth of Massachusetts
City/Town of
a -- Pumping
System S
Y p g Record o d
, .. - Form 4
DEP has provided this form for use by local Boards of Health, Other farms 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 [hey use. The System Pumping Record must be submitted to
the local Board of [-health or other approving authority within 14 days from the pumping date in
accordance with 310 OMR 15.351,
_ __._._ ___..___._ ..._ _-- _ HOUSE front ck side rear left righ
A. FacilityInformation _ _.__ ........ .. ...._. .._____...._.. BW�DING� a
front back side rear left right
Important;When
DECK: under
filling out forms 1. System Location:
on o computer,
use only ttrra tad a' F
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key, C IVy(rawn Stale Zip Code
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Addross (If different from location)
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cnyrr0Wrr state _..
Zip Code _..
Telephone Number
B. Pumping Record
1. Date of Pumping 2 Quantity Pumped.
ate Gellons
3. Component. (—] Cesspool(s) eptic `rank ❑ Tight 'rank ❑ Grease Trap
Other (describe): _..._.. .--- --- -- _. _._
4. Effluent Tee Filter present? �_� Yes _ No If yes, vvas it cleaned? [] Yes [ No
5. Observed condition of component pumped
6. System Purnped By
Dave 11ney Mass 1AA95E Mass 1AD31Z
Name Vehicle License Number
Baieson Enterprises, Inc.
Ct�rrrhany
7. Location where contents were dispos€:d.
GLSD
___8__1`2__ t
signatufe, of Nrauler Date
Signature of Recelving Facility(or attach facility (eceipt) Date
t5torm4.doc- 11112 Sryslern Pumping Record - Page 1 of 1