HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 86 FULLER ROAD 5/14/2025 Commonwealth of Massachusetts OWn of IVI4n
- City/Town of �o�er
_ System Pumping Record MAY � 52025
Form 4
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DEP has provided this form for use by local Boards of Health. Other forms r-nay �, � ��
, ���
information must be substantially the sarne as that provided here. Before using this form, Che,Cl �tur
local Board of Health to determine the form they use. The System Purnping Record must be submitted to
the local Board of Health or other approving aulhority within 14 days from the purnping date in
accordance with 310 CMR 15.351. _—
______._...--- HOUSE: Cfj2Za>back side rear left Ph
A. Facility Information BUILDING. front back side rear left right.
Important:Mort DECK: I-hider
(Illing out forms 1. System Location
on the computer,
use only tha tab ��/ --- — __... - ..
-.__-. __.
key to move your Address
cursor-do no! (VIA
use the ret !
urn ---- --- ------ ----..-.---- 018-yr?
key. Cityffown Slate Zip Code
2. System Owner:
Name ---
ar�rn
Address(If different from location)
MA
Clt /Town --- ---- -- - --
Y Stale g� } Lip Code --------
telephone Number
B. Pumping Record
_.��/�`Zs boa
1. Date of Pumping ---- -- 2. Quantity Pumped. -----
Dale Gallons
3. Component'. Cesspool(s) ( Septic Tank ❑ 'fight Tank ❑ Grease Trap
Other (describe): ----- -.__. ----/- ._.-__. ------ -- —- - - -----—- ------- -- ----_-.
4. Effluent Tee Filter present? [] Yes ( j IVo If yes, was it cleaned? ❑ Yes No
5. Observed con It{on of component purnfped:
6. System Pumped By
Dave Tl n ey _. _. Mass 1 AA9 5 E _ ass '1 A U 31 Z
!Jame - Vehicle License Numb ---- --
gMeson Enterprises, Inc
Company
7. tion where contents were disposed.
(�l.S
Signature a( Hauler Dale � - --
Signature of Receiving Facility (or at'lach facility receipt) (late
Ifform4.doc- 11f12 System Bumping Record Pare 1 nl .t