HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 64 FOREST STREET 5/1/2025 Commonwealth of Massachu ow of Noahnsetts darer
City/Town of � MAY
F J'° S stem Pum in Recand0
25
.0 a
Y p g
Form 4 ec*l0th
Depcjrt
DEP has provided this form for use by local Boards of Health. Other forms rnay be us'c , but the
information r-nust be substantially the sarne as that provided h-ere. Before using this form, check with your
local Board of lieakh to determine the form Mey use. The System Pumping Record rnust 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 baclid t rea left rig
A Facility InformatiOl1 BWLDiNG: fronC tack . Ides rear left rig)
Important.Whin
OFCK: under
(MIng ouf terms 1. �ys I t ocal,ion
on idle cornputar, T
.._._
use only tho tab
key to Cnove you( AddrQlss. _.._ _.. _..... -.,-. - .. _..... ...
Cursor -do not P � d MA 4 y r Apo
use the relurrro 1-. — ---..__. __._._ _.._ _..__.. __..___.. ____...__
key City/rowo Stale lip Code
2 Stem
Owner
k.-=1
Narne
t� ..
Address (If different from localion)
MA _
Clly/Town
S181 LIp Code __. _.._..
Telephone Number
.....
B, Pumping Record
1 Date of 4'urr7t7inq cial _-�� -.. ___...-- 1, Quantity Pumped. Gallons
3. Component'. (_ cesspool(s) Septic.rank ❑ Tight lank ❑ Grease Trap
E] Other (describe) _. r-,- . ........--._
4. E ftIuent Tee Filter present? +- yes (� No If yes was It cleaned? cs L� No
S. Observed co ntlition of cor7 ponenl pucriped
6 Systen-i Pumped By
Dave I inc Y..._... Mass 1AA95E Mass 1AD31Z
-- ... _._ -- ---- -------- - _.... ----.
Name Vehicle License Number
E���tesor�( Fnier��ris��;, Ir�c.
C.,campar,y
7 t_oc;alion where contents were disposed,
GAS( ....._
Signuturra of Hau r Date _.
Si nature of Rec2lving Facility(or attach f<'ar,ilj(y receipt) Date
5(or(114 VoC 111i2 ,)yslern Purnpmg Record Page 1 a(t