HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 162 GRAY STREET 6/4/2025 *dbver
Commonwealth of MassachusettsOWn Of*'th
City/Town of
System Pumping Record Jtj/V 16 2025
Form 4
'De
DEP has provided this form for use by local Boards of Health, Other forms may Vgr-tMetj
information must be substantially the some as that provided here. Before using this form, the Ywitj) YOL)f
local Board of Health to determine the form they use, The System Pumping Record must be submitted 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: "`fr front hack side rear IeT-N r- m
A. Facility Information BUILDING:(— back side rear left right
Important: When DECK: under
filling OLA fOFMS 1 System Location:
on the computer,
use only the tab A;2--
key to move your Add
cursor-do not 4/14L4, MA
use the return ----------------- ------
key, City/Town slate Zip Code
2. Systeln Ouwner
Name
Address (If different from location)
MA
CIty/Town Stale Lip Code
Telephone Number
--------------......
B. Pumping Record
f/c
1. Date of Pumping Oate 2. Quantity Pumped
3. Component: ❑ Cesspool(s) Septic Tank ❑ "Fight Tank ❑ Grease Trap
[] Other (describe): —------
4. Effluent Tee Filter present? 0 Ye No If yes, was it cleaned? ❑ Yes No
5. Observed condition of component pumped.
6. System Pumped By:
Dave TIn Mass IAA95L Mass 1AD3
Name Vehicle License N-i-u ber
Bafeson Enter rises, Inc
Company
7, c 'on where contents were di5po5(:,,d.
Signature of Hauler Oa[e
Signature o f Receiving Faciliky Forattach facility receipt) Date —
J6(orM4,(toC, 11112. System Pumping Recor(l Page i of 1