HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 371 SUMMER STREET 4/8/2025 ���
(�[}��[�{][�������|f� of K8�]����{������ff� /UV�l '��~�� ����Commonwealth^ . Massachusetts. �' '~'^,^rn/»wt/V�r
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System Pumping----vec�� —�� - APR 14 ^�O�
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Form 4
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th
OEP has provided this form for use by local Boards of Health. Other forms may be e k��
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information must be substantially the same as 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 bosubmitted io
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CKUR 15.351 HOUSE: front �:c3kside rearrej r
A. Facility Infor BUILDING: front back side rear left right
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Important: DECK: under
�n��mm�n
filling out forms 1. System Location:
on the computer.
use only the tab
key m move your Address
numo/-dunoi MA
use the return —
kay. City/Town "`°`e Zip Code
2. System
MA
QtyfTown 8I iFE� 12, Zip Code
Telephone Number
B. Pumping Record qJOL5- /
1. Date of Pumping Date Quantity Pumped: Gallons
3. Component: 7 Cesspool(s) Septic Tank 77 Tight Tank D Grease Trap
[] Other (describe):
4, Effluent Tee Filter present? [] Yea No If yes, was it cleaned? F-1 Yea [] No
5, Observed condition of component pumped,
G. System Pumped By:
OoveT/n
eate Enterp!�es, Inc.
Company
7. L-Gcjktion wheredisposed',
GLS
'�Ignature of Hauler Date
t5fom4dnu 11U2 System Pumping Record 'Page 1 of