HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 91 CROSSBOW LANE 4/17/2025 �- Commonwealth of Massachusetts f �. � ,
City/Town of f 11dove,
System Pumping Record
Form 4 APR 8 202
DEP has provided this form for use by local Boards of Health. CJt the „1A Abe used, but [he
information must be substantially the sarne as that provided mere. Before Lasi�1'" a I�, ck with our
local Board of Health to deterrn'ine the forrn ihey use. The System P��roping Record m§w'submik ed to
the local Board of Health or other approving authority within 14 days from -.he purnpincg date in
accordance with 310 CWr 1 r) 351 _ _.--.-___ __. _
HOUSE: front bac4slcie` rear leftCri
l
A. Facility Information — BUILDING: front back "`sl e rear left real.
Important; Whorl DECK: under
fllldng oW forms 1 System location: �
on the computer,
use only the tab ` � t
key to move your A d ess
Cursor-do no( �r
use the return — -._.. . - - ..- - -..._. .. .._-....__ MA --- yL
ke CIly�own Slate Zip Code --
Y
1141D
2, S tern Owner
Y
tel✓fl t
j Address (if different f(orn location)
MA
Cil /TownSlate ® Zip Code
N Telephone Number
B. Pumping Record
1. Date of Purnping -- " _ __w 2 Quantity Pumped.
7alE.
Gallons
x 3. Component: Cesspool(s) Septic Tank ❑ Tight Tank g [I Grease Trap
f C] Other (describe): _.-----.------__._._.___._.__..._._.__
4. Effluent Tee Filter present? C] Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
I
6. System Bumped By:
Dave Tine Mass 1AA95B Mass 1AD3'1Z
E Narru, VcY7irir; License hJurr-+bcr
(3ateson Enterprises, Inc.
Ctyn7pany
l
%, t_ocafion where contents were disposed:
GI 5D
r
.signature of uler Cate
I
SI nalurc or F;te&eiv ng f-acilil or all rci-i faciiity rncelpl) [)ate
15(orm4.doc- 11112 System Pumping Record- Page 1 of 1