HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 285 REA STREET 7/8/2025 Commonwealth TOO of ®rth
.� ealth of M ssac husetts 417doVer
r City/Town of _
System Pumping Record JUL 8 2025
Form 4
ea/th
DEP has provided this form for use by local Boards of Health Other forms may be ,Pmgr'Me
information must be substantially the same as that provided here. Before using This form, check 7I h yow
focal Board of Health to determine the forrn 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 C M R 15.351. - --- _.`-------____-- ------_.-----__._
_ HOUSE: r o e back side r e a e r i('h t
A. Facility information BUILDINGi front back side rear left rif;ht
Important:Whon DECK: under
(Illing out forrns 1, Systern t_ocation�
on the cornpulor, �j
use only the lab Zk37
key to move your Address
cursor-do not /��
use the relurn —'-"-= ------------ ---___ MA
Y
ke City�l"own Slate Zip Code
2. System Owner:
_-._ _._.__-._ .. __--
Haute
Address (If different from Iocalion)— --- _ ---- — - "—" "- -
MA
Clty/Town stale Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dal- 12 ---- ?, Quantity Pumped. ------
Gallons
3. Component: [] Cesspool(s) Septic Tank ❑ Tight Tank Q Grease Trap
Other (describe): —- ----- ----------- -------- --------
4. Effluent Tee Filter present? _ Yes No If yes, was it cleaned? (_-_ Yes ❑ No
5, Observed condition of co f onent p mped:
B. System Pumped By:
Dave Tiney Mass 1,41,A95E s '1A031 ,
Name Vehlcie l-icensc. Number
keson lnferprises, I�-nc- ---------
Company
7. Location where contents were disposed:
LSl)
Signalure of Hauler Dale ----- ----__-..__--
SI nature of Receivin Facili y r )
g g h'(or attach faCIIIC tfiYC2I al UaIB
Ib(orm4.doc 11112 ,Sys Bumping Record f'atge 7 or 1