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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 30 JAY ROAD 5/5/2025 ` � commonwealth of Massachusetts . G21.. CItyiTown of System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forrns may be used, but the information must be substantially the sarne ,as that f�:rrovided hr re. Be)fora; using lhis form, check with your local Board of Health to determine the fon,in they use. The System Purnping Record must be sutbmitled try the local Board of Health or other approving ,autho(ity within '1 el days fror-n the pumping date in accordance with 310 CM 15 351 HOUSE: f r o n back side rear l eft rip h A. Facility information BUIt.DINGi front back side rear left right mportant; When DECK: r-j nC,ler Mling out forms 1 System l..ocnition. on the con'ipuler, use only the t a t> key to move your Ad(res cursor.do(rot -- MA use the return Lip Code_ y 2. Systern Owner: 5 Narne rnLrn ' Address (If differ©nl (ram location) MA _ Clt /Town Y Stale Lirl Code Telephone Nurnt>er B. Pumping Record 1. Date of Purnpincl 2 Quantity Purnped -- ®c _._._..._..._. (_—_ale Gallons 3. Component: r J Cesspool(s) ( _ Sepfic 'Tank [uJ Tight Tank ❑ Grease Trap Ej Other (describe): _ _-- _.----.. a. Effluent Tee Filter present? C_J Yes� No If yeas, was iC cleaned? [_] Yes ( j No 5. Observed condition of c,ornponent pumped: �VISrM 5, Systern Pumped By: Dave TIneY _ _ ._ Mass 1AA95E ass 1 b Nan1Ei Vehlcie l_icensr. Nu r e2feson Enlerprisps, Inc, Cornpany T icon where contents were disposF°d. GLSD Signalure of Hauler Cale Slgnalure of Rpcelving f acility (or attach facility rercpipl) Date -- i5formA.doc• 11f12 Systern Pumping Record Page 1 of.i