HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 458 FOSTER STREET 3/31/2025 Commonwealth of Massachusetts To Wn of NOrth 4 n do Ver
City/Town of
System Pumping Record APR -2
Form 4 2025
DEP has provided this form for use by local Boards of Health, Other�*ohyqwgtbut the
information must be substantially the same as that provided here. Before using th your
local Board of Health to determine the form they use, The System Pumping Record must"behfitted 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: fron ' back side rear left<r
A. Facility Information BUILDING: � nt' back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab
--------------
keV to move your Address
cursor-do not MA
use the return -—-----
key. City/Town state Zip Code
2. System Owner:
Y iGo,
Name
Address (if different from location)
MA
City[Towr) State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped'.
3, Component: El Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
0 Other (describe): ---------
4, Effluent Tee Filter present? [] Yes No If yes, was it cleaned? Yes [] No
5, Observed condition f component pumped,
6. System Pyrnped By.
Dave Tlne Mass IAA95E Mass IAD3-12�
Name ��-hlcle License
2afeson Ent r-i-ses, Inc,
Company
7, L tion where contents were disposed:
I
LS)
..............
0
P—iignaitlure Hauler Date
Signature of-f� eci;i7vfng'F�ihi—y(or attach facility receipt) Date
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