HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 165 FOREST STREET 4/15/2025 Of
orth
Commonwealth of Massachusetts 4 4AndoVqr
City/Town ofAPR 1
- S ystet-n Pumping Record 2025
Form 4
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DFP has, provided this form for i..rse by Iocal R00rds of Health. Othc;r formes may be used but the
information must be substantially the same arc that provided here. Before using This form, check with your
local Board of Health to determine the form they use, The System Pumping Record must be submitted to
the local Board of V`Iealth or other approving authority within 14 days from) the pumping date in
accordance with 310 CMR 15.351 -- ---�__...____ ____..._..__.—__-----------.-----_-.--
__.__._ HOUSE: front ., a c k side rear left(r i f;h
A. Facility Information BL)ILDING: ront ttiack side rear left right
Important;When DECK: under
fllling out forms 1 Systern t.oc@tion;
on the computer,
use only the tab _� 9
key to rnove your Address
cursor-do not
use the return MA
key, City(Pown State Zip Code
2. Sy f tern wner:
� ,.
Name
Address (If different from location)
M P,
C(t (Town
Y Slain Zip Cade
Telrphr7rre Piurr)ber
B. Pumping Record
1. Date of Pumping _ _..__._.___..._. 2 Quantity P�lmped
Date Gallons
3, Component: Cesspool(s) �! Septic Tank ❑ Tight Tank ❑ Grease Trap
C� Other (descrlhe): _. _...._......._ ./____ _------
4. Effluent Tee Filter present? (.) Yes N0 If yes,, was it cleaned? (---) Yes 0 No
5, Observed condition of component pumped
6. System Pumped By:
Dave TIney Mass 1AA95F Mass 1 D31Z `
Narne vehicle L.ice,nsr.
@afeson Fnierprises, Inc
Corrtr>any
7, lion where contents were disposed.
ILSD
__. .._ _ . _ _-. --- _ __ __ _ . lee =___ ___ __.._-__ --
Slgrratulre of Hauler Dale
Slgnaturr of Fe--c-eivIri Facilik p
p y (or attach facilely rF,cei () Data
l5formel.doc, 11112 System Flumping Recgrd 4 aqp' 1 ql 1