HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 485 FOREST STREET 7/7/2025 row/7 Of
"L\ Commonwealth of massachusetts rth doVer
' City/T o w n of _w AUC I 12025
n Pumping Health Z)el)a
-` Form 4
rtme
DEP has provided this form for use by local Boards of Health, Other forms may be use , but the
nfomrahon rnust be; substantialiy the same as khat provided here. Before using this form, check with your
local Board of f--lealth to determine the forrn trley use The Systern Puinping Record must be submil to
the local Board of Health or other approving authority within 14 nays from '.he purnping date in
accordance with 310 CMf= 15.351
--. --
HOUSE: front bark side rear left ri
A. Facility Inforr'T anion SUILDINGi front back side rear left ril
Important: Wh€in
D F C K j n d e
filling oul (ormv System l.oC sink) .I
on Mc,
use oolyufhe tab r C
key to move you( dd s5....
cursor ,€90 not �'
MA
U S€; 1 h Ei r E;(U I ll .... ...,._..a/_l ... �_. .^' _:.. ..,,.... __._ _. _......_.._ c
key C,(ly 1"owrr JI l Z.I Code
). System Owner:
�S yj ------ _ __._....
F`r-_• fJ�rri e
lII(✓!i '�Yf
Addross (II elifierenl Irorr7 lar,alion}
MA
city/Town Sla(e y Zip Code
Celephonw Num)er
B, Pumping Record
1. Date of Purrlping Cale---.. _ °_ ___-.. _._..-. 2, Cuantity Pumped'. � � _..._..__....
Gallons �-
1 Component: (-� C;esspooi(s) Septic tank. ❑ Tight Tank Grease Trap
[_] 0iher (describe),
4. Effluent Tee Filter frresenl? 1'es If yes, was it cleaned? 0 Yes No
5. Observed condition of componer-if purr-If,red
6 Syste r 1 r=l,irnf e5/c 3y
Fy ' Mays 1Apf)5E ass 1AfJ31
Jhr n€E; Vehicle t_.Ic;ense Nurnber
Bafeson [`ntEirl)nses, Inc.
Company
7 c G tiUr wirer( cor tents were dispo,,ied.
- ........
Signatwo € f Houle( rate —.._
Sltlnraiure of F:c>c�Iviny F<Icllity (or al(arh (ar,IIIPy rgs(,,clryl} C7ale
_-..._
l5lorrn4 doc, I M 2, °3ystern flurnping Record , Pap, 1 f7f i