HomeMy WebLinkAboutSeptic Pumping Slip - 336 Boston St - 12/4/2024 - Septic Pumping Slip - 336 BOSTON STREET 12/4/2024 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 CMR 15.351,
HOUSE: front(G-3c side reat��1 ' right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not IJA MA
use the return --------
key. ityrTown State Zip Code
2. System Owner-
e
Address-(i f different—___Fro"
MA
- I�yffown State
_Telephone N`uG`ber _
B. Pumping Record 12 /24
1. Date of Pumping '5'ate I 2. Quantity Pumped:( Gallons
3. Component: F7 Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
F-1 Other (describe): ------
4, Effluent Tee Filter present? [I Yes No If yes, was it cleaned? ❑ Yes 7 No
5, Observed condition of component pumped:
Pq r&-c
6. System Pumped By.
Dave.T riey MasslAA95E ass I AD3 I Z
Name Vehicle License
Bateson Enter R�Lses,
Company
7. on where contents were disposed:
GLSD
—----------
171,Vq
'Signature of Hauler --------- Date
Signature�f Receiving,—Facility—(or atta—ch--fa-'c�il-i-ty�re-c—elpt—) -Date
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