HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 855 WINTER STREET 12/19/2024 Commonwealth of Massachusetts
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System Pumping
Record
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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 ur other appnoving authority within 14 days from the pumping date in
accordance with 31OCK4R 15.351.
A~ Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 855V0n�rS�e�\
key m move your Address
cursor do not
North MA Ol845
use�om�m
key. City/Town ^a= Zip Code
2. System Owner:
~--~ KarenMawm
Ada ifferent from location)
978-387'82U2
In I
B. Pumping Record
12Y19/2O24 1500
1. Date ofPumping 2. Quantity Pumped: Gallons
1 Type mfsystem: Fl Cesspool(s) Z Septic Tank [l Tight Tank [l Grease Trap
[] Other(describe):
4. Effluent Tee Filter present? X Yes [] No K yes, was iicleaned? X Yes El No
5. Condition of System:
Good, system dproperly
0. System Pumped By:
Jason Elliott S71437 orV85257
Name Vehicle License Number
|vesterand Elliott Services LLC-DBAJaeon
Elliott Pump ing
7. Location where contents were disposed:
6LSD