HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 74 STONECLEAVE ROAD 4/7/2025 Commonwealth [}fk�������������ff� T~^- r�& �
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System Pumping Record APR 14 �O��
Form 4 - �"�*
DEP has provided this form fo b | | 8 d f H �th C}th
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information must be substantially the same as that provided here. Before using thig forotmt�iihyour
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31UCK8R 15.361
HOUSE: front-oac�—side rear left Ehb
A. Facility Information BUILDING: front back side rear left right
under
�
Important:When DECK
m|mguut forms 1. System Location:
on the computer, 'l
use only the tab -r
key to mmevqur Address
cursor'uonot
MA
use the return
kew. ~'`''~~^ °a-"t P Zip Code
2. SystUwz
I VI/Ell C -
Name
Add
MA
C|tyfTown �� ���__��
State Code
lip
B. Pumping Record q17
1, Date of Pumping 2. Quantity Pumped.
3, Component: [] Cesspool(s) Septic Tank Tight Tank Grease Trap
[] Other (describe):
4. Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? E] Yea F] No
5, Observed condition of componentpumped:
G, System Pqmped By.
Oev�T|nMass IAA95E/' Mass IAD31��
Name Vehicle License Nl�mber
eateson FnterEises, I
7. tion where contents were disposed:
GLS
te
t5fom4duu 11112 System Pumping Record 'PagnI of