HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 19 BEAVER BROOK ROAD 4/14/2025 Commonwealth of Massachusetts Over
GU >� City/Town of A,
VM
Systern Pumping Record
Form 4 ��
L""'�Oartment
DEP has provided this, farm for e,asry by local 13oorrl s of Health. Other forrn, may be used, but the'
inforr-nation must be substantially the sarne as that f.)rovided here. 30orra using Phis forrrr, check with you(
local Board of Health to determine the forrn They use, They System Pur�nping Recofd rr'u, t be SUbrrlitted ict
the local Board of Health or other approvir'ig authority wi hin 14 days from the pt�jrnping date in
accordance with 310 CMR 15.351
H0USI , front back' side rear left rif h
A. Facility (11C7rr71tlOr1 BUILDING: front .rc side rear Ief-t right
inportant: Wham D F CK t.;nder
filling out forrns 1. Systern .-ocation.
on the cornpr.rlor,
use only the tab -AG « A,M(!4-'
key to move your Address
us(S h - et root �,C^
use the return — - -- _.-_..--- .._._ _.__.____.___ MA
key. City/Town State Zip da __..._ ...
LII----I
2. System U ner:
ft>7L
f �
` 14arrte
sir
nttrrro !. `t�
Address (If different from location)
MA
--------.. -_ -.----
CityfTown dale Zip Code
Telephone Number
B. Pumping Record
1, Date of Pumping _. t_ .__.___...__. 2 r�uantity Pumped — .._..._.___---------_..
C7ate Gallons
3, Component: ❑ Cesspool(s) Septic Tank Tight Tank ❑ Grease Trap
L� Other (describe):
4. Effluent Tee Filter present? [ponenes �.._] No If yes, wa.s it cleaned? j `res [� No
o 5. Observed condition f ornt pumped,
_- ------
6. System Pi,Imped By:
Mass 1AA95 Mass 1A,D31Z`
Marne Vehlcie License t mber
@3� eson En�erprlsps, Inc_
Cornr>>any
7, tion where contents were di5posr d:
-----_-_ __..
Signature of Hauler Date
Signature of Receiving facility (or attach facility receipl) Date _ ._..,.
i5forni4.doc- '11/12 Systorn Pumping Rerord •Pacge 1 nr� r