HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 333 CANDLESTICK ROAD 3/24/2025 Commonwealth of Massachusetts 110*97
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System Pumping Record � '
Form4 -alo
DEP has provided this fo/m for use by local 8oau]y ofHaa|{h, Other may'be
information must be substantially the eame as that provided here, Before using lhia form, ��ckwith your
local Board of Health Lo determine the form they use. The Syuharn Pumping Record must be submitted io
the local Board of Health o/ other approving authority within 14 days hnrn the pumping date In
accordance with 310CMR 15.351 �3ac
A. Facility Information BU ILDING: f ront back side rear 011(511 r�ght
Important:When DECK: under
kUhg nut forms 1 System Location',
on the computer,
use only the tab
key to move your ^u*rem
cursor'uunot
use the return MA
key. °`x' "— map Zip Code
2, System Owner
10/
a Me
MA
Qwn Zip Code
—t-T�phone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped.
Gallons
3, Component: El Cesspool(s) Septic Tank Tight Tank Grease Trap
C] Other (deaoribe)�
4, Effluent Tee Filter present? Yea No If yes, was it cleaned? Yee Fl No
5. Observed d/
6. System Pumped By.
DaveT|n
e8feSOn Enterprises, I
Company
7, tion
ignalure of Hauler -ba
ature ty(or atlach facility receipt) Date
t5fomn4.duo 1182 System P«mpin8Record 'Pagn } of