HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 26 EASY STREET 4/16/2025 (e,
Commonwealth of Massachusetts
City/Town of row/7 Of
System Pumping Record North An 10
per
Form 4
APR
DEP has provided this form for use by local Boards of Health. Ot forms may be use , but the
information must be substantially the same as thot providedlaav!�j, g Ihis form, check with your
local Board of Health to determine the form they use, The System PL]rnpi lust be submitted to
the local Board of Health or other approving authorityy within 14 days from the Purl i
accordance with 310 CMR 15.351.
HOUSE: Cron -back sid'e rear left i g I)'t
A. Facility Information BUILDING: front back side rear left rig t
Important: When DECK: under
(IIIIng out forms 1. System Location:
on the computer,
use only the tab - 2Q,
key to move your Address A f
cursor-do not
_k,J-\ MA
use the return -5(yffowo
key. state Zip Code
2. System Owner:
Name
&:M
Address (If different from
-
MA
CIty/Town We Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2 Quantity Purnped�
Date -Gallons—
3, Component: ❑ Cessipool(s) Septic Tank ❑ 'Tight Tank ❑ Grease Trap
[] Other (describe).
4, Effluent Tee Filter present? E3 Yes No If yes, was it cleaned? j Yes [] No
5, Observed condition f component pumped,,W(.
-----------
6. System Pumped By.
Dave TIney Mass IAA95�4�MEISS IA[3`3--t•
Z
Name Vehlcle License
eifeson Ente.rprjs L±s,-Jn c -------
(,'orT)pany
7, alion where contents were disposed:
QLSD
-Signature of Hauler Dale
---
Signature of-R—ecaVllr attach-facility-- ----receipt)-- Date
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