HomeMy WebLinkAboutSeptic Pumping Slip - 399 Summer St - 11/25/2024 - Septic Pumping Slip - 399 SUMMER STREET 11/25/2024 Commonwealth of Massachusetts
City/Town of
System Pumping 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 the pumping date in
accordance with 310 CIVIR 15.351.
HOUSE: front vack side rear left Qig31 '
A. Facility Information BUILDING: 1'ront back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab e4- —-----
key to move your Address
cursor-do not MA
use the return -
key. City/Town State Zip Code
2. System Owner:
Address(if different from location)
MA
City/Town State Zip Code
-Telephone Number
B. Pumping Record
1. Date of Pumping Dat_Ire IL541�------------- 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank 7 Tight Tank 7 Grease Trap
Fj Other (describe):
4. Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? ❑ Yes 7 No
5. Observed condition of component puMped:
6. System Puimped By:
Cave They _ Mass lAA95E aasLI�A >V
Name Vehicle License Nurn e—r "
Bateson Enter
Company
7. 6;tion where contents were disposed:
GLSD
'Signature of Hauler Date
Signature of Receiving fWc-H-11y7_(or a—ttach,facility receipt) Date
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