HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 56 BRIDGES LANE 3/26/2025 Commonwealth of Massachusetts
Town a f
City/Town of ®r h
_ System Pumping y p g Record
2� Form 4 APR 5
DEP has provided this form for use by local Boards of Health. Ot ay be used, but the
information must be substantially the same as that provided here. El f y E?P rm, check with your
local Board of Health to determine the form they use. The Systern Purnping Reco f riubmitted to
the local Board of Health or other approving authority within 14 days from -.he purnping date In
accordance with 310 C,MR 1 S 361 _ .._.
---.-------_-_ t-1OUSL front ha .,k stile ea I�ft rigt
A. Facility inforrTlatton BUILDING: front bac e rear left rigl-
Important;When
DFCK: under,
(Illing out forms 1. System Lo 'tion
on the cormutef, /
else only the tabs @ " �
- ___-__
key to move your �dd�rss
cursor-do not /
use the return -- - . ---1 _d- bll— -- --... ------ MA Y
key cilyrrown 51ate Code —
k
2. Sy err) Owner:
l L—]iPli
Name
r
` leltvn
r l�ddress (il different from loaatlon)
' MA
CI(y/7owr7 State _
Zip Code --
Telephone Number
B. Pumping Record
i 1. Date of Pumping - 2. Quantity Purrnped�. ------......._
Date Gallar s
3
3, Component Ej Cesspool(s) Septic Tank ❑ Tight Tank Grease Trap
L_] Other (describe):
P 4, Effluent Tee Filter present? es No If es, was it cleaned? i;�Ye<s
{ t_--i YNo
5. Observed condition of component pumped:
t
6. System Pumped By:
Dave tine — Mass 1AA95E Mass 1AD31Z
Name Vehicle License Number
B2keson Enterpnsps, Inc
Company
7. Location where conten ere disposed:
GLSD
3iy 1.n81 11 ure of Ho 11 ule t etc
---- ---
Signature Uf V�t,raelv4ircl racifily{ur r:rll;rci7 (arili(y receipt) f7atcr
a
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