HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 600 FOSTER STREET 3/17/2025 Commonwealth of Massachusetts down
Of Ill An do Ver
City/Town of
System Pumping Record APR -2 2025
Form 4
0 4�op
DEP has provided this form for use by local Boards of Health, Othe?Po but he
l
information must be substantially the same as that provided here. Before using this but
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: frontC side rear left Q—iS-D
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1 System Locati n:
on the computer,
use only the tab
key to move your Add ess
cursor-do not MA
use the return -----------
key. cityrrown -Zip-Code
2, System Owner
-----------
-Narne
return p'
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number one
B. Pumping Record
1, Date of Pumping 2. Quantity Pumped,
—bate Gallons
3. Component: El Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
[] Other (describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned?A Yes [] No
5. Observed condition of component pumped,
6, System Pumped By,
Mass 1AA95E 1AD31Z—,
Name Icle License Nu
9ateson EnfoT Lises,jnc.
Company
7, '"c,04ion where contents were disposed.
Signature of Hauler C7ate
Signature ofRecelving Facility r attach facility receipt) Date
t5form4.doc- 11/12 System Pumping Record-Page 1 of 1