HomeMy WebLinkAboutSeptic Pumping Slip - 350 Berry - 11/13/24 - Septic Pumping Slip - 350 BERRY STREET 11/13/2024 Commonwealth of Massachusetts
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u LL =a City/Town of
System Pumping Record
r - Form 4
DDT' 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 they use. The System Pufmpfng Record must be submitted to
the local Board of Health or other approving authority within 14 days from -,he purnping date in
accordance with 310 CMR 15 351 -_.._._ __._—__ - �"_ - .....
--_---___._._... _ ..__ HOUSE font . - side rea left right.
A. Facility information BUILDING. front back side rear left right
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B, Pumping Record
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1. Bate of r�L.irrlping �1e L Quantity Pump
f �...� cesspool(s) P ❑ Tight
3. Con7 ponent: Sa tic Tank Tank ❑ Grease Trap
Other (describe): _.. _.._ ............
4. Efflueot Tee Filter present? [] Yes Cw o If yes, was it cleaned? ❑ Yes [] No
u. onent pt,Jlnf�ed
Observed f���7rT1 �
6. System Pumped By.
(Latvc 11rley Mass 1faA95G Mass 1AD317_
Jarr7r: Vehicle License Number
Balesori En er�)rlsps, Inc,
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Conrl7s{ny
7 Location where contents were disposed
']LSD
Sig rra(ure of rIauI.e Da( __.._._ __.._...
Si nature of Rec,eivinc f acilit y p)
g a Y or �aClacYi (arilit� rr.cr,�� l Date
51c>rn74.JUC� 111i2 Syslern Pumping Record ' Page 1 r)f 1