HomeMy WebLinkAboutSeptic Pumping Slip - 325 Summer - 11/18/24 - Septic Pumping Slip - 325 SUMMER STREET 11/18/2024 Commonwealth of Massachusetts
r= = City/Town of
System Pu
mping umping Record
Form 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
NODS front ack side rea Jeff right
--- -— - ..
A Facility information BUILDING. n back side rear e right
Important:When DECK: under
frliing out(orris 1. System Location:
can the computer, r J arse, only the tab
key to move yr,ur W-uOU-1
cutsor-do nor
MA
use the return
GII (Town
key y S(a(e ode
2. Sys -n Owner:
Narne
Addross it different from location)
MA
Cfty� Own State
Lip Code
elephone Nurnber
E3. Pumping Record ---- ------_
1. Date of Purnping o i -- .. ._....... - -- <. antity Pumped
- Gallar7s
7/
3. Component: Cesspool(s) _ Septic Tank ❑ Tight Tank ❑ Grease Trap
( 1 Other (describe): _..__ ----_._. _ --
4, Effluent Tee Filter present? ❑ Yes Clo If yes, was it cleaned? ❑ Yes ❑ No
5 Observed Condition of conrponent purrpe(J
5. Syster-i Puri'ped By.
DaveIineY_ Mass 1AA95E Mass 1AD31Z
Name Vehicle t_lcense Number
Bateson En erl)rlses, Inc
ron,pa�7y
I-ocatlon where contents were disposed
GL5D
Signature of Hauler Datc
,ignature of Receiving Facility (or attach facility rc.ceipl) Date
t5iorm4.doc- 11112 Syslern Pumping Record • page 1 of 1