HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 192 STONECLEAVE ROAD 6/12/2025 Commonwealth of Massachi,isetts Of41011447V011
City/Town of
Systern Pumping Record 6-20,25
Form 4
DEP has provided this form for use by local B(..)ards of Health. Other forms may?(N bLJI �N'
0 ,
information must be substantially the same gas that providers here. B u efore sing lhis f ck WIII) You(
local Board of Health to determine the form they use. The System Pumping Record f'r))t,ist b ttnitted 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: front bac sik�
A. Facility information BUILDING� front back side rear left rifI)t
Important:When DECK: under
(Illing out forms 1 ly Veocation:
on(he computer, --I
use only the tab S
key to move your Address
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cursor-do not
use the return 'M A
Zip Code
2. ern Owner:
LI Name
Address If dTfferenl from location)
MA
CI(yrTown a I e Zip Code
Telephone Number
B. Pumping Record
1. Date of PLIMPing
2. Quantity Pumped,
GateGallons
3, Component: ❑ Cesspool(s) Septic Tank ❑ 'Tight Tank ❑ Grease Trap
0 Other (describe):
4, Effluent Tee Filter present? (-) Yes If yes, was it cleaned? E-1 YesNo
5, Observed condition of co ponent pumpgd:
6. Systern P4jmped By:
Dave TIney Mass IAA95E (Mass 1AD31Z
Name Vehicle License kh.m ber
gnfeson
Company
7, Ltion here contents vvcre disposed:
Ai-
Signature of Hauler Date
Signature of Rec elvIn Facility (or attach facility receipt) Date
I5(orm4.doc- 11112 Systern Pumping Record pate 1 0l 1