HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 SPRING HILL ROAD 4/7/2025 To"n
Commonwealth of Massachusetts "I
City/Town of
n
System Pumping RecAPR
ord1 225
_. Form 4
DE:P has provided this fornn for use b local Boards of Health. Other fore
p - y c forms r pt "4pntt h r,
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 Purnping Record must be submitted to
the local Board of Health or other approving authority within 14 days fronr the pumping date In
accordance with 310 CMR 15 351
HOUSE front back side rear left ri#'ht
A. Facility Information BUILDING: front back side rear left right
Important;When
DECK: under
filling out forms 1. System I._ocation.
on the computer,
use only the tab — �L
key to move your Addres
cursor-
use the return ,a MA
do not
key. City/Town State Zip Code
2. Sy tern caner:
Address(If different tram location)
MA
Clty/Town St atn Lip/Code
Telephone Number
B. Pumping Record
y � ,
1, Date of Pumping ._.______.._.___ 2. Quantity Pumped
Date Gallons
3. Component: ❑ cesspool(s) Septic Tank ❑ 'Tight Tank ❑ Grease Trap
❑ Other (describe): ........ _--...
4. Effluent Tee filter present? F3 Yeas No If yes, was it cleaned? � ) Yes C] No
5. Observed condltlon of c n ponent purnped
6. System Pumped By:
Dave TlneY Mass IAA95E Mass 1AD 1
Name Vehicle License Nu 7ber
eateson Enterprises, Inc,
Company
7. tion where contents were dispose
G D
ignave of Hauler Cate
Signature of Receiving Facility(or each facility receipt) Date.
Worm4.doc- 11112 Systern Pumping Record Page 1 cf 1