HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 280 CANDLESTICK ROAD 3/21/2025 tv
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_ Commonwealth of Massachusetts a/t /701,
V
ei
City/Town of _
APB
a _ ° System Pumping Record
0
r +y? Form 4 heaa
DEP has provided this form for use by local Boards of Health. Other forms may b , he
information must be substantially the same as that provided here. Before using this far ck with your
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 310 CMR 15.351. _.__ __..._.._.._....
HOUSE: runt ack side rear left rif hr,
A. Facility Information BUILDING: ront back side rear left righr
Important:When DECK: tinder
filling out forrns 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not t MA t
use the return ----.---_ .__-- _...__._._._.__.. _.__ _.
key Cityffown State Zip Code
101/Ll —A- 2. System Owner:
r
Address (If different from laoation)
------__
MA
Clty[Town State Zep Code —
Telephone umber
B. Pumping Record I
1, Date of Pumping -- � l_Z _____-...___._.._. 2. (quantity Pumped:
Date Gallons
3. Component: Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
Other (describe): ------_..___ __._...._.___—___._.___....___.._.___..._____--
4. Effluent Tee Filter present? n Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped;
G, System Pumped By:
Dave Tlney _ ._._...____ _..__ �- ,
Mass 1AD31Z
Name mber
eatescn Fnferprises, Wnc.
Company
T —tion where contents were disposed;
ULS
3 A
r�U
Signature of Hauler Date —
Signature of Receiving'Facility(or attach facility receipt} gate
t5form4.doc- 11112 System Pumping Record •Paget of 1