HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 970 JOHNSON STREET 12/10/2024 Commonwealth of Massachusetts
City/Town of
=- System S y Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health, Other forrrts may be used, but the
information must be substantially the same as that provided here. !tefore using this farm, check with your
focal 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 aL�lthoriCy within 14 days from the pumping date in
accordance with 310 C MR 15 i`j1 �
HOUSE front bark sic re (r le right
A. Facility Inforrnation BUILOING� front back side .rear left right
Important: When
DECK: under
filling
th computer, 1, System �LUGIrr
o P �
use only the tab _
_ _ _.... __.._ _ _.__ .....,-_. __----,.._ .......
key to move your Xdress
cursor-do not Cfli � MA
use the return —. - -----...... ..... ........ __.—.,._..__._-_.-__._._. ----.__...-..___ --_-_._—___..._.. ___.__
key Sfa(a Zip Code
2, stem Owner',
t. �+
N a rn e
�eltva
Address (if different from location)
MA
_... _._,____ _ ._... _. _._ __.... _ _, _-------_ __....-_
C;ftyfTown State Zip/ode
ode
Telephone Number
B. Pumping Record
_ _ __��
1, Date of Pun ping ate 2, Quantity Pumped.
Gallons
3, Components c-_.� Cesspool(s) F eptic 1"ank Tight Tank ❑ Grease Trap
❑ Other (describe) __. _...... _.-.__._.
4, Effluent Tee Filter present? ❑ Yes 1<0" If yes, was it cleaned? ❑ Yes ❑ No
5 Observed condition of component pumped
6 System Flumped By
Dave Tiney Mass 1AA95E Mass 1AD6`IZ
--
Narnr; Vehir,Ie License Nramber
132teson Enterprises, Inc,
Company
7 Location where contents were disposed:
GLSD
Signature of Hauler Cate
Signature of Receiving Facility (or altaeti facility (eceipt) Bate
l5form4,doc' 11112 System Pumping Record Page 1 of 1