HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 56 GRAY STREET 3/26/2025 Commonwealth of Massachusetts
r City/Town of _ Town of NOrth
- System � o�
° Pumping y ping Record
Form 4 APB
DEP has provided this forrn for use by local Boards of Heald. other forms may be used, but the
information must be substantially the same as that provided t R / f 'in this form, check with your
local Board of Health to deterrnine the form They use. 'The System Purnp t be submitted to
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the local Board of Health or other approving authority Mhin 14 days from -he pumping date in
accordance with 310 CM(k 15,351,
HOUSE fron hack side rear le rigf
A. Facility informatiorl SUILDIN . - ort hack side rear left rigr
Important;When
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key to move your d r ss
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use the return _ __-- --__-_ -. _.._ ...._____ .....__..,-- _.__.�,._
key- lyrrown Siele Zip Code
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Address (if different from location)
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CllylTown SIatE � � Code
telephone t umber
B. Pumping Record
I 1, Date of Pumping _..__ __.__. ------ Quantity Pumped'. _..__ .____..__......_.
ale, Gallons
3. Component [j Cesspool(s) Septic `tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe),
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4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pun-sped:
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6, Systen-t Purnped By
Mass 1AA95E Mass 1AD31Z
i Name Vehicle License Nurnber
Baa eson Enterprises, Inc.
Con-,pany
p 7. Location where contents w,4 disposed.
GLSD /
s
Skgnalme of Hauler Date
- -- -
- ------.
Siynasture of fieceiviny Facility (or al(arhi fs-rrukty rerwlpl) (late
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