HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 78 LACY STREET 11/2/2021 Commonwealth of Massachusetts
City/Town of
System Pumping Record •
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms may be'used,but the
information,must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use. The,System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Locationdnag.,
rgh ront o ous , Left/Right rear of house, Left/right side of house, Left/
Right side of bullLeft/Right front of building, Left/Right rear of building, Under deck
use only the tab --- — — —
keyto move your Address
cur y�
cursor-do not
use the return City/Town State Zip Code
key.
� 2. System Owner:IL AV
Name
nrim ,
Address(if different from location)
City/Town State -Zin Code v
Telephone Number
B. Pumping Record
1. Date of Pumping pate _ 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): - -
4. Effluent Tee Filter present? ❑ Yes li3- o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condi ion of compone t umped:
6. System Pumped By:
A F 5'8a I
NanMTESON ENTERPRISES,INC. Vehicle License Number
111 ARGILLA ROAD
Comp DOVER-"MA 01-810
7. Location wher or}tent ereelt�posed:
C�
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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