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HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 80 PHEASANT BROOK ROAD 6/16/2025 Commonwealth of Massachusetts �0[VrlOf410 rth City/Town of n System Pumping Record ,llf `- Form 4 N 2D2 6 q y� DEP has provided this form for use by local Boards of Health. Other forrr �rN��,y sed, but the information must be substantially the same as that provided here. Before using f W0Q/'r' kfwilh your local Board of Health to determine the form They use. The System Pumping Record must t mitted to the local Board of Health or other approving authority within '14 days from the pumping date in accordance with 310 CMR 15,351 e rear _-� ri Information BUILDING: sdft ff A. Facility ---��-^ - e rear le i D NG: front back_ __.__ ____.__ g1)t Important;When DECK: Under (Kling out forms 1. System LQLiation: on the cornputer, y� use only the tab V" ft"A.n � Zrr:, key to move your Ad _.... _ —-- ._.. -- _.-__--- N f ress t culsor -do not I v� .-an (./�Q}^ MA use the return key. ityrrown State — Zip Code -- r 2. System Owr n�`leu r Y\ Narne Bran (s `v Address (If differ©n1 from location) — --^— — — -- _-- ----- ------__. MA _ Cifyl7own -- — --------__-- SIaIe-- --- � lip Code Telephone Number - B. Pumping Record 1. Date of Pumping � � -- 2. Quantity Pumped. Gate Gallons 3, Component: Cf cesspoo)(s) ( _ Septic Tank [� Night Tank ❑ Grease Trap n Other (describe): --- ___----- 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes [] No 5. Observed condition of cornponent purnped: 6. System Pumped By: Dave Tlney Mass 'IAA95E ass 1AD31 Name Vehicle Ucense Number gnfesan_Enfer Company 7, Lion where contents were disposed: LSD Signature of Hauler Dale _— — _ -- Slgnalure of RPcelving Facility(or-attach fa tac1IlCy rerer-ip- 1) Dale Worm4.doc, 11/12 System Pumping Record page Iof