HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 112 ABBOTT STREET 3/26/2025 Commonwealth of Massachusetts
City/Town of Qr
System Pum in RecordIVOrth �""
Form 4
r APR 2
025
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be: substantially the sarne as that provided here. Be - is form, check with ynr.,r
local Board of Health to determine the form they use, The System Purnpin4 p submitted to
the Focal Board of Health or other approving authority within 14 days from -he pumping I t
accordance with 310 CMR 15,351, _ ._______ _._--
c HOUSE. front back sid rear left igl
A. Facility Informatior7 BUILDING: front back side rear left rigr
I Important:When _ DECK: under
N Toting out forms 1 Sy tern.Lo Ion �
or)file computer,
use only the tab __
key to move your ress _
cursor -do not q
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use Ihte return _
key Cliy!('own si.+Ic, Zip Code
416�l
Y Z—] 2. Sy tem Owner:
All";,
ame1:
t ___ Address (if different from Vocation)
MA
City/Towr'i slate /�"- ~� 1 ZIp C de
-
Telephone Number
B, Pumping Record
i
1
1. Date of f urnping 2)
dale — 2, Quantity Pumped. /�Cls
4
3. Component: [ ] Cesspool(s) _-Septic 'Tank ❑ Tight Tank (-J crease Trap
f ❑ Other (describe): ...... _._.....___-.__ _.._. _ � ._.__.
4. Effluent Tee Filter present? 0 Yes/ No If yes, was it cleaned? ❑ Yes ❑ No
D
p 5. Observed condition of component I,urnp
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6. Systetri Pumped By.
(Nave f ine Mass 1AA95E Mass 1AD31Z
_...._ .__._Y . ._ .__-__ __. — _ __...__..
Narne Vehicle L icense Number
I Bakeson Enterprises, Inc.
Company
7. Location where contents were disposed:
GLSD
I Signature of .ruler (7este
- _. . ___
Signature of Receiv4ny (=acilaty( r ai(.ch facility receipt) )ate -
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