HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 426 SUMMER STREET 4/25/2025 Commonwealth of Massachusetts
City/Town of
— ,k System Pumping Record
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 forrn lhey use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from -.he pumping date in
accordance with 310 CMR 15,351
------- HOUSE: front(b'ao side rear iecf_,-�'
A, Facility Information BUILDING: front back side rear left rig
Important;When DECK: under
filling oul forms I System Loc Lion
on the cornpulef,
Use only the tab ` 'W
key to rnove yQuf 0 8
cu(sor -do not -112 MA 's-
use the retuln —i-&-4, -----I �� - ----- 11-------------
key cl(y/-ro-r) slate Zip Code
2. SyOwner;
-Wst
Add(oss (If difle(on[ from location)
CIly(Town
Telephone umber
B. Pumping Record
1. Date of Pumping ------ 2,'Quantity Pumped.
Gallons
3. Component ❑ Cesspool(s) Septic Tank ❑ Tight Tank C1 Grease Trap
Other (describe). ------------ -------
4. Effluent Tee Filter present? D Yes No If yes, was it cleaned? ❑ Yes ❑ No
S. Observed condition of component fournped:
------------------------
6, Systern Purnined By.
Dave Ti Mass 1AA95E Mass IAD31Z
- - -- L'Ie-Y------------------ ------
Narne Vehicle License Number
Bileson Enterf)risp-s, Inc.
Company
7, Location where contents were disposed:
GL5D
Slgnacure of hauler
D a(e
---------------------
lgnatu(e of Receiving'Facility (or attach facility receipt) Date
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