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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 63 BRADFORD STREET 4/7/2025 Commonwealth of Massachusetts orf� City/Town Of n over System Pumping Record 4PR1420 25 Form 4 aril DEFT has provided this form for use by local Boards of Health. Other forms mayR t the information must be substantially the same as That provided here. Before using this form PAtlith your local Board of Health to determine the form they use. The System Purnping 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 CCMR 15 351 ----- — HOUSE, front back side rear eft rigt A. Facility Information BUILDING: front back side leV rigl- Irnporkant;When DECK: under f(Iling out forms 1. ystern L cation; on the computer, use only the tab �fe "�r _-- .__. --- - -cursor-do norirrMAY Y useI t i e return - -. _ _ _-_..--- __.._. __.. .,. ...._ ._.._._._... _..._..____-- ---__. ____—�.....,____ h- .__.-__-�� key, ,Ily/Town Slate 7_(p CoUe 2, System Owner ��� tJarrre _----------.. ------------ ---- __._._._--.. ...... --. nnxn tti Addr©ss (il difierenl from laca�lon) M A, CIIyTawn date --___._ _ LVp soar Te e e Nurnber B. Pumping Record Vt 1. Date of Pumping —__. __ 4 _._.._. 2 Quantity Pumped'. Da6e Geleons 3 Component (w„} Cesspool(s) Septic Tank ( ] Tight Tank (—] Crease Trap i ❑ Other (describe) - ___--____--_-- i I 4. Effluent Tee Filter present? 0 Yes No If yes was It cleaned? ❑ Yes ❑ No 5. Observed condition of componenl pumped: 6. Systen7 Pumped By. Dave Tiney Mass 1A.A95D Mass 1AD31Z { Name Vehicle Irer se t}umbP,r Baa eson Enterprises, Inc company 7. Location where contents were disposed: GLSD Signalrrre of Hauler Date `3ignaiure C>I ReceivIng Facility (or srU.r Yr (.rr;ilily rw,,eipl) Tale — ..__.. 15form4.doc- 11/12 Systern Pumping Record - Page 1 of 1