HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 54 VEST WAY 6/5/2026 ofIVOrth
C;o�mmenweaItP-� of Massac�-,tusE tts
C i t y/ t ew r7 f _ JUN 15 266
Purnping Re rci
(� Forn7 4
epa
DE P has pry>viC ed INS f0rrn for use by IocM f3owd s of I_1ealth. C)Mer fof ms may be +.a e(ld l)ul the
nforr-nation must be subat��antiedly the rsarne Ds that provided hem. Before using lhis form, check, wilt) yc)u(
Oct Board of Health to determine Ih(,~, fern') They usm They Syster-n Purnping Record must be tsubmitte rt I()
Me local Board of Health or Who asp,;provmg stutt.mTy wi(Wn 14 days from Me pumping date;In
rsrcofdance wily 310 CMR 15 ;351 _ _-
_ JU'�f frr7rrt )�rcl< . .i<Jr, rt,,� l f� fipf7lC irlc rn� It t
A. Facility Irlfc�rrr� �tiof7 ult.r>IN(, frr�r,t r.�>rrk right
11"POMrriat: When DECK. under
My wo ft;rr" 1 System t_o uation
on Iho corn{.ui(l r,
u e rrn(y line lab
key Ira rnrwri ycr,r,ir ftrkarr.ss ---
u „th (et not PVIA
C" n {�
ese
tlti> return .__�.___ ._=— -Y-'--_ - -.��___._ ._... _ ...__ _.._ _._......, _---._______
Y Cily(f,owo W-E L+t CCJCIe
t. By-Step)) C)Awncr:
TWO ----------- Cf
AtStlros, (Ir diffcrc.nl €yarn Icaca6ir�r7)
MA
�r'r Corlr
lelee ar'ae f�lurnhe=r
Fit- ping Record
4
1. Data of Purnping C�ai 2. C.�r,antily Pumped
(,allans
3. ComTonent: (- ) CeS7 tf)001(s) [ ,c,piic "tank I-..._) Ti, hrt Tank
�l �.__� G r Ey a s ca Trap
00fer (describe,,)- -
I B`HWent Tee FiHer presmu? (__} `r e s (�� Jc> If yes, was it cleaned? (-_] Yes (� No
3. Obsewed condition of comp of)(2nt (>r.rrr7p_>e�J
rr
& ystem PyWed By:
Dave TIney M s s i/ A95E Mass 1AD317
t�7�ir as VetrlCle ( ir_cr:;e Nur7 b r _..
` hson Enterprises Inr _.
Company
l_ocaUon v1� Conti; its were r.)ispor,5c(J
.>iynalurra Ca(4-Ir�riler Orrlc _._
`7lgtralt�rr; Cr( f2rer,t,ivirry I rj��ility (r>r ,rll>rtai fFir,ility rr,r,�i�>t) r)t71r�
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