HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 784 WINTER STREET 12/8/2025 r'f
Commonwealth of Massachusetts v r
City/Town of
= System Pumping Record C � �
F o r rn 4
DE P has provided lair, forn`i fof use by local E:oa(ds of Healih. Gthei, forr'ns rr`1aa a ' tll Me
informa(lon must f;)ee substantially the sarne @s Ih al p(ovlded d-iere. Before using this farm, check wi ) your
local Board of Health to determine, the form they use, The, Systern Purnping Record must be submitted to
Me local Boarr,1 of t iealth or offie r approving authority within 14 clays from tee purnpiog elate in
acc,c idance with ,310 CMf; 15,351
_
t-IOUSC mart hack side rear I t �r
A. Facility lnforf'natiO11 6WLDiN. ---runt I)ac e.ir� rear Ief1 r
DF M Lander
Important! When
Wkng out dorms 1. SySteln LOCEItiOfT
on llte cornpulal, t p
e only the 1E+Ils
y Io move your Fed<irrisv
Cursor . do no(
use the return --
knY C;IIy�1'orr Slalr Zip Code
J( S y s t e i C 1,., .1taFf'�t,f
Yritvn
!'00((9sa (if diPtedrorrl arum Iocalivil)
C."ily7rco—Wo 7 ¢'; i ) Code
Telephone Nurnt)er
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B. Pumping Record !(
1. Date of Puml Ding Ir e - - 2. Quantity Purnped G@liari -------
3. component) c ersspooi(s) []�8optic Tank ❑ Tig-f7t Tank ��] Grease Trap
L_ Oiher (describe) _._ _.. ___-- _. .___.___ ___......-_.___
4. Ffflueo( "1 ee Filter present'? [._a Yes�cr If yes, was it cleaned? [�� Yes ( IVo
5. Observed condihon of component purnpe
O ve f lr ey.. Mass IAA9sF- Mass IADX331Z
sva rrr3 A/r-+tnclG l,lrr.nsr�, Nrrrn�r�r
I�)Ic?rE:)risf-�s, Inc.
� mptarry
Loca(ion v heie3 Con(ents were,, disposed
_.._..
>iransirrrc3 0l F1aul
_ - ---.. -- _ ..___...... -
'Igmiure of R c�eiving FaoHfly (or ilIa,ich fUcili(y receipt)
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