HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 103 JOHNNY CAKE STREET 6/24/2025 Commonwealth of Massachusetts �� r�� ,`� '� , t, And
OVer
City/Town of
System pumping Record JUN3p
Form
4 �025
DEP has provided this form for use by local Bora(ds of Health. Ofhe fcS''r�ri � but he
information must be substantially the same as that provider) hone. Before using 'k wilt) you(
focal Board of Health to deterrnine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CM 15.351
_ HOUSE: front back(i)rear(23 right
A. Facility Information -------- ----- BUILDING: front back side rear left rif;t,t
Important:When DECK: under
filling out forms 1. System location:
on the computer,
Li-se, only the lab —
key to move your Address
cursor -do not N1�
use the return -- — __ _.----- ---_
key, crown Slate, Zip Code
2. Systern`Owner.ur�rn
Address (If diFferenl from localion)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record r/
1. Date of Pumping � 2. Quantity Purnped _�---- --
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
�) Other (describe): __�--------- -----_-- —_-- _ _--
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
S. Systern Pumped By:
Dave 1'Ine ass 1 A SE Mass 1 AD3'1 Z
_—Y_-----------------------------------_._...---- --- _—_- ---------_..--- ------
Name Vehl1lr° u nber
Baieson Eriierpri ' Inc.
Company
7, Location where contents were disposed:
Signature of Hauler ----- Dale
9 9 Y (or attach facility (eceipt) Date ------ --�_.__._.------_-------.__.--
f acilit
SInature of Recelvin
15(orm4.doc, 11112
System r'umping F:ecofd Page t of ,