HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 155 CHRISTIAN WAY 12/31/2024 4
ii'
Z Commonwealth of Massachusetts
City/Town of
o JA iv
System Pumping Record 72025
Form 4
DEP has provided this form for use by local Boards of Health. Other forms ma he
information must be substantially the same as that provided here. Before using this form, c ck 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 pUrnping date in
accordance with 310 CIVIR 15.351, ----------------
HOUSE: (;front ack side rear le I QJ,,h,ft "V
-t rig
ro;
A. Facility Information BUILDING: ront�back side rear lef
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Add ass -------
cursor-do not MA �j
use the return
key. City/Town State Zip Code
2. System Ow er:
-Name ------------ ..........-
m location)
Address(if J�fere—nf
MA
Z`lty7fo'Wi- State Zip Code
--------------
_ Telephone Number
B. Pumping Record
1, Date of Pumping D a 2. Quantity Pumped,te Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank Grease Trap
❑ Other (describe): -----—
4. Effluent Tee Filter present? [] Yes No If yes, was it cleaned? ❑ Yes ❑ No
5, Observed condition of component pumped:
6, System Pumped By,
.Dave Tln e Mass I AA 9 5 E ass 1 A D31-&,
Name Vehicle License Nu I ber
eateson EnfeTjis_q�s, Inc,
Company
7, 'on where contents were disposed,
LSD
........... ----------- ------- --------
_____,_. _ _________ __._________ __ __ _ __,� �__
------------
Signature of Hauler Date
Signature of Receiving Facility(or attach faciliCy receipt) Date
t5forrn4.doc- 11/12 System Pumping Record -Page, 1 of 1
