HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 164 VEST WAY 4/16/2025 Commonwealth of Massach(�seft3
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System Pumping Record��O�� /�over
System
Form 4 A��
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OEP has provided this fo/mfor use by local Boards ofHeaKh Dth
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but the
information must be substantially the same as that provided here. �n��� be check with you,
local Board of Health to determine the form \hey use, The SystemPumping —~ `" m0eU (o
the local Board of Health or other approving authority within 14 days fromfromthe pumpingN��t
accordance with 310CK4R 15,351
HOUSE: Q��n back side rear left iphf.
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A. Facility information B U I L DI N G front back side rear left r i h t
Important:When DECK: under
filling out forms 1 Systern L i
on the,computer, \
use only the tab Un
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y move your Address �
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use me returnreturnreturn ' -- ___ �
xur� City/Town— ~'~`e Zip Code
2� Syst rn [>
Name ��----'
To-
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MA
C|y/To*nZip Code
B. Pumping Record
1, Date of Pumping A41-2 2. Quantity Pumped,
ate Gallons
3. Component: Cessipool(s) Septic Ta n k Tight Tank Grease Trap
Fl Other (describe):
4, Effluent Tee Filter present? 0 Yee No If yes, was it cleaned? [] Yes [] No
5, Observed condition
O, System PVmped By,
Dave Tine
Name Vehicle License NuCeLr
eafeson Enferprises,
Inc,
Company
7.
ignature of Hauler Date
Date
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