HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 164 MILL ROAD 4/15/2025 Commonwealth of Massachc.asettsOf At, r7
City/Town of _ nVp
System Pumping Record APR 18
.=r 7 Form 4 202
information roust be substantial) the same as thr,t rovidecl hero. E3n � Do t.''�cac,l, but the
DEP has provided this form for use b local Bc)ards of Health, Ott
Y - P fore r�rsj" rm, check with your
local Board of Health to determine the form they Lise. 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: front ark side rear Ieft rl..ht
A. Facility Information BUILDING: front back side rear left right
linportant: When nUX: under
tliling out forrns 1 Systern Location
on the cornrru(ef,
use only the tab 4�
key to move your Addros
cursor-do ool
use the return -..— - v1F�
key. Cityfi"own State Zip Code — --
U11--
, 2. System U ner,
Id -
_._& _---------
Address (If different from location)
MA
___________-___..___----___._
Clfy/Tawn 3t£�,in Giro Cade
'fe iephone Number
B. Pumping Record
a
1. Date of Pumping _.__. .! ......__......___.. 2. Quantity Pumped.
Gate Gallons
3. Component; ❑ Cesspool(s) ( ] Septic Wank ❑ 'Tight Tank ❑ Grease Trap
Ej Other (describe): __ _ _ .-_-_.__.
4, Effluent Tee filter resents ( Yes No If Ens was it cleaned2
- present?y � � _ yes,.�, -� Yes
5. Observed condition of cor-nponent pumped,
6. System Pumped By: _
Dave TIneY __. Mass 1AA95 Mass iD31Z
_ _,..__. _ -_...-._ __-- -- --..___..
tJarttr� \fehlc u er
2a�escn Infecprises, Inc
Company
7. Tian whore contents were: di5po e,,d:
_
�LS�U
16nalure of Hauler Dale
Signature of Receiving Facility (or attach facility recr t) ruler
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