HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 127 VEST WAY 2/18/2025 ��� '� ���� A��*�
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System Pumping Record
Form 4
Health Department
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 mr other approving authority within 14 days from the pumping dote in
accordance with 310CMR15.351.
A~ Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tam Vest Way
keymmove your Address
cursor-do not
North MA 01845-2226
use�e�mm
key. City/Town ="e Zip Code
2. System Owner:
�---' Carol Morino
781-708-0879
B. Pumping Record
O2/18��2� 15OO
1. Date ofPumping 2 Quantity
Date � � Gallons
3. Type ofsystem: Fl Cesspool(s) E Septic Tank Fj Tight Tank El Grease Trap
LJ Other(describe):
4. Effluent Tee Filter present? X Yea [] No |f yes, was itcleaned? X Yes El No
5. Condition ofSystem:
Cloggedh|t* Good, systembproperly
O. System Pumped By:
Jason S71437urV85257
ame Vehicle License Number
|veoter and Elliott Services LLC-DBAJason
ElliottPumping
7. Location where contents were disposed:
GLGD