HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 455 CHESTNUT STREET 3/26/2025 Commonwealth of Massachusetts To Wn of NOrth ver
City/Town of
APR - 2 2
System Pumping Record 025
Form 4 Health
DEP has provided this form for use by local Boards of Health. Other forms ma b 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 or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15,351.
HOUSE: front backside rear right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
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key, City/Town State Zip Code
2. System Owner:
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Name
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MA
City/Town State Zip Code
C
_Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: J!;�0
Date Gallons
3. Component: F7 Cesspool(s) Septic Tank ❑ Tight Tank E Grease Trap
0 Other (describe)-. -------------
4, Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? E Yes ❑ No
5. Observed condition of component pumped:
-----------
6. System Pumped By:
_gave ........... Mass 1AA95E( Mass 1AD31Z
Name Vehicle License
Bateson Enter rises, Inc.
Company
T .on where contents were disposed:
'o7 0 UG�LS D
Signature of Hauler Date
Signature of Receiving Facilityfwc�liityi receipt) Date
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