HomeMy WebLinkAboutSeptic Pumping Slip 12-16-2024 - Septic Pumping Slip - 443 BOSTON STREET 12/16/2024 [`[)mm[)n\@ea|fh of Massachusetts
City/Town of
o
System Pumping Record
Form 4
DEP has provided this form for use by i000| Boards of Health. Other forms may be used, but the
information must be substantially the same an that provided here. Bofona using this form, check with your
|ooe( Board of Health 8r determine the form they use, The Syobsrn Pumping Record must besubmitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31OCKAR1S.351
A. Facility Information BUILDING: 4rrr:ccont back side rear left right
HOUSE: fro�nt5bacl� slide rear left(r=ight:)
Important: DECK' under
�n��mmen
filling out forms 1. System Location:
on the computer,
use only the tab
key m move your Address
cursor-du not
0A
use the return
key. `'^'' ~-^ State Zip Code
_ System
Name
_�ddress (if Yifferent from location)
MA
CIty(Town State Zip Code
lephone Number
B. Pumping Record
Date Gallons
3. Component: Cesspool(s) Septic Tank Tight Tank Grease Trap
[] Other (describe):
4, Effluent Tee Filter present? [] Yen No If yes, was it cleaned? L-1 Yes 0 No
5. Observed condil
G, System Pumped By:
DevaT|
Name Vehlcle License Nu er
2ateson Enterprises, I
Company
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