HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 100 VEST WAY 4/2/2025 Commonwealth of Massachl,asetts ` t' o
x
City/Town of _ vet
System Pumping Record APB 202
:x Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be°e) f "t
information must be substantially the same as that provided here. De fore using this form, the w lWYOUr
local Board of Health to determine the form they use. The System Purnpincd Record must be submitted Ica
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 1.5 35i
HOUSE~: front back side rear left
A. Facility Information BUILDING: front back side rear left riftrt
Important:Whon DECK: under
fl(Ih,g Out forms 1. Systern Location:
on the computer,
use only the tabi ._ ..... .,..... . ----- —
_.__
key to move your Ad rays
cursor-do not ,
use the return ---= - `'- _____ -`.__._._. _.-_.___ MA __
key. Cityrrown State ---__—._._.__.____ Zip Code
2. SysC m O ner.
A
Address (If different from location)
MA
Cffy/Town Stag Zip Cade
Telephone Jumb,
B. Pumping Record
1. Date of Pumping — - _ 2. Qtit Pumped.
P g Gate uan y P Gallons
3. Component: C] Cesspool(s) / Septic 'rank ❑ Tight Tank ❑ Grease Trap
0 Other (describe) __.._ _-._-___.. __.._ ___._._ _._.._.,__
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? ] Yes ❑ hdo
5, Observed condition f component pumped,
6. System Purnped By:
Dave TIneY _.._ Mass 1 AAg56 Glass 1 A10"31
Name Vehicle License N nk�er
eateson Fnierprises, Inca
Company
T tion where contents were disposed:
GLS
Signature of Hauler Date
._____-____
Signature of Receiving P acility(or attach facility receipt) Crate
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