HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 203 MILL ROAD 4/16/2025 ��
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Form 4 1-10al" D
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DEP has provided ihis form for use by local Boards of Health. Other forms may be used
information must be substantially iho same as that provided here. Befura using this form, check with you,
local Board of Health to determine the form they use, The System Pumping Record must be submitted io
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310CK4R 15�351 HOUSE: (fron� back side rear r i P,h T.
A. Facility |ilfn[D0afiOn BUILDING: front--- buck side rear left--- 'i�h(
|mpor,tant:When DECK: under
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2, S Owner-
Name
Address(if different from location)
MA
CKy(Tono
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B. Pumping Record
I, Date of Pumping k, k�'� 2. Quantity Pumped,
Date Gallons
3, Component Cesspool(s) Septic Tank Tight Tank Grease Trap
[] Other (describe):
4, Effluent Tee Filter present? E] Yes k1 No |/yes. vvayi� c)e�neU? [� Yes Fl No
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5, Observed condition of component pumped,
0. System PympedBy�
DavaT|ne
Vehicle Li
2 ku En�erprises,
Inc,
Company
7, ,t�oa�!oo where contents were disposed,
aulef Date
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