HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 25 SUNSET ROCK ROAD 4/15/2025 ,row
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Commonwealth of MassachLisetts �
Gx= = City/Town of V r
System Pumping Record 20 1 25
Form 4
provided has " S xrcal Boarr
. - �isCrf f tc���tltll C7Chr r (c�rrrt, � � r-� i k ul thr�
local anonoard fuH be ubstantiiallystchory lace as that Provided hero. 9efore using Ihis`f heck rwith yow
w y System P gRecord
P r7��tust be submitted ur
to determine tt1F farm the, r use, Ct1t; ,, stem P�.trrl In RECOrC1
the kcal Board of Health Or other approvv)g authority within 14 days from the pure Ing date in
accordance with 310 CMR 15,351 _—_..__.__. _._ _.---
HOUSE: front ack ide rear left r Cght�
A. Facility Information BUILDING: front back side rear left rifgr,t
Important:when DECK, jnC1Pr
filling out forms 1. System Location
on the computer,use only the tat)
key to move your Adc r 5s
cursor-do not
use the return � .. --- ___.____. _--- -___.. ._ , _._.__�_.__ MA.__...� �t
key. City(-rown State Zip Code
— 2. System t.,.Owner:
Name
_.-------------
Address (If different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping — _.__—_. _, 2 Quantity Pumped _
�a1e Gallons
3. Component: ❑ Cesspool(s) ( Septic -tank [ Tight Tank Grease Trap
( I Other (describe): ___..._ /✓. --
4. Effluent Tee Filter present? (.] Yes ] No If yes, vvaS it cleaned? [r...3 Yes ❑ No
5. Observed c,onditio of component purrrpeca:
6. System Pumped By.
Mass '1 AA9 5 B ass 1 F�,C�3 31 Z
Nan)e Vehicle License Hum. r
eafeson Enferprises, Inc_
Cornpany
7, ctfion where contents were disposf:d,
LSD
Sgrraiura o Hauler (.Isle
Signature of Receiving facility (or attach facility receipt) Ditr.
t5fcrm4.doGr 11112 Sytstern Pumping Record • fuage t of 1