HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1041 JOHNSON STREET 6/16/2025 ` Commonwealth of Massachusetts er
C i f y T o W n o f JUN 16 2025
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SyStem PLIMping Record
Form 4 "� )th
ePartmetlt
DEP has provirJr�Cf this fo(rn for us(, by Ocal E3ut'11rJ', of Her llkh f)fher (c)m7l may l7r used, bui (he
information isms 1. be su )slanhally IY1n sarne �s 0mt pro',/Ided h rc. [-Iofore usinq Ihi, frw-n cVrrck with you(
local Board of f ie.Mh to detterr-Nne l,he (orn) lhey uj�,O t lrC Purnpiog Recom must C;t t,r�C7cr�ltlt�°rJ 1�;7
Cha Iocr11 E3catard of f iealltl Or cllht r pprovirig aullmi ily wilhin 14 days from the pumping cl a[e io
accordance with :3,10 C l\AR 15 ;351.
A. Facility Information f (J IL 7ING fron �Ck
1)ack slde rear left rtgt,
Important:Whoo D F hK n d e
(Illlog out forrns 1, Systt'm (._t:7c,a1,icrn
no lhr,, compule(, // C// f1^.//�nc r^1
E i s e, only l h o l a t> _._.......,..4.`�'•Z..(..-..-,So!..�.!...�,°7yr,-._...) '7`-___----
key!o rnova yo,�rr Address
cursor •do nol /1 IAA 0,9 Y5
use the retwn .--- -- --
key cityffown Slale Zip code—_._._-_ ---____--
2. >y.s(ern Owner
`1 F� N,)rne
ly— (J•�
Addross(I(diffe(onl f(orn Iocahoo)
MA
C lil (Town .... .. _.-..._
y 5191e rip Code
TeleptiuireY Pdrarntarr
E3, Ptlr-np nc R.ecarri
1, (ante of Pumping
P � 5alr 7. Qa.aslntity �urrr�cacs�
Gallons
3. Component; ❑ Cesspool(s) j } Sep(ic Tank [_] Fighl Tank ❑ Grease Trap
[] 0(har (desCribr,) /
4. Effluent Tee Filter present? [.. Yes I^Jcr i( yels,,, waas it cleane(l'> C� ','es (_] rio
5. Otaserved condition of con,iponrew parr-npeo
6. System Purnped By:
Dave Tiney Mass 1laA95E Mass 1AD312
_...-
Mama,) v./nrilcar L�ct:r7,�„t3 N�,rnP,7er
RAnn F-n(er r«ec, Ins_ _ __.._
Com{zany
7, Loc ion whCre cunlenl* were di5po3cd.
igrttllurtl of Ydtlt.rlE'�rlry
SIgnalane- of F;oceIv{ng f .aril'tlty (or a('lact) 4ucilily (nceipl) Orate
If,IOrrn4I.doc, 1111)