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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 767 JOHNSON STREET 4/25/2025 Commonwealth of Massachusetts 4 City/Town of r- ;ri._ = =° Systern Pumping Record a _ Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the Information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the farm Ihey use. The Systern Pumping Record must be submitted to the local Board of f-iealth or other approving authority within 14 clays from -he purnping date in accordance with 310 CMR 15 351, t{DtJSE — front ha(ksiderea! left)rI(3A. Facility Inforr-nation BUILDING front bae rear left rig IrnrrortarYt:Whearr DECK: undr?r hiding oul forms occafl l l (he r.`arr7puler, Userxr � h u,,e only the latr t„ � ' key to move your F dd es r^ cursor -do not M (f /yr use; fire, reluln / .��✓ V .,-- (VA _ —_— _ __. — — — kk3y, Hyffowrr, Strste Zip Code 2. S em Ow r�c�r: f Addr©ss (If dl(ieredl7l from loc,aUCrn) MA _Z __C_..ode_.--- __...__ CIIy�I"own �51a1e - Telephone Number B, Purnpincg Record 1. Date of f�)urnpinq Date___ _ - — Quantity Pumped: Gallons -3. Corr7ponertt: Cesspool(s) _ Septic -frank ❑ Tight Tank Crease Trap Olher (describe) 4. F (fila.rnt Tee Filter present? [=j Yes r\lo If yes, was it cleaned? (� Yes No 5. Observed condihon of componeni purnpeu:� 5. System Irlt.Jrnpeof By: Dave Tiney _...._. _ Mass 1A.A95E Mass 1AD31Z Ns�rnc? Vehicle Llceose Number E32teson Enterprises, Inc. -- - -. Company 7 Location where contents were disposed: GL5D Signa(ure of H Date _ nature of f�e;c>etviny F=aelllty fur attach facility reccipl) Dais 5(orm4.doc 1"1/12 System flurnping Recorta Page 1 of i