HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 117 BROOKVIEW DRIVE 4/21/2025 OW17 of ho'orth
Commonwealth of Massachusetts4nd0l/er
City/Town of
APR 2 8 2025
Systern Pumping Record
Form 4 Ith L)ePartM,,,t
DEP has provided this form for use by local f3wvds of Other fortes inay be used, bul lhe
information Must be substantially the same as that provided here. Before using this form, check will) your
local Board of Health to determine the torn-) Mey use. The System Pumping Record Must be submitted lo
the local Board of Health or other approving authority within 14 days from the- purnping date in
accordance with 310 CMR 15.351.
4.
HOUSE: front back 6J.d,orear right
A. Facility Information BUILDING: front back side rear left fq-,ht
Important: When DECK: under
filling out forms 1. system Locat 0
O -
use the computer,se only the tab
key to move,your Adores
cursor-do not
use the return MA
key. ZKYT-own stale Zip Code
Id Q— 2. System
�*S� ��6 -------------Name -----
Address (If different from location)
------
MA
CltyfTown Stale,
21 Code
Telephone Number
B. Pumping Record
21
t// ki1,
Date of Pumping Gate --- -- 2. Quantity Pumped.
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ "Fight Tank ❑ Grease Trap
0 Other (describe),
4, Effluent Tee Filter present? Yes I\,I0 If yes, was it cleaned? Yes ❑ No
5, Observed condition of cornponent pumpecJ,
6. System Pumped By'.
Dave TIney Mass-1 AA 5 E _Mass 1AD3)Z9
Name Vehicle License W er
Gnfegorl lnfprorises, Inc.
Company
7,(,-tt*, where contents di5loo,5cd.:
----------
Signature of Hauler
---—------ -----------
Signature of Receiving,Facility(or attach facility receipt) Date
15(Drrri4.doc, 11112 System Pumping Record Page i or t