HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 19 CANDLESTICK ROAD 7/21/2025 Commonwealth of Massachusetts Town of NOfth Ancli,,v.
-10 City/Town of
Systern Pumping Record AUG 112025
Form 4
Health n
DEP has provided this form for use by local Boards of Heakh. Other forms myyW46momp"
Information must be substantially the same as Thal provided here Before using this form, check with your
local Board of Health to determine the form they use, The Systern Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from -.he pumping date in
accordance with 310 C M R 1 5.3 51 -----
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HOUSE: front( b@ck),sif:71erear e of
A. Facility Informatior-I BUILDING: front�—b�acside rear left riR
Important:When DECK: under
(IIIIng out forms 1. Systern Location:
on lhe computer,
use only the lab .--t ----------
kf�y to move your AU f e 8
cursor - do nor
use the rvtufn �J--f
MA
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key cilyiro,, State Zip Code
2, S y s t e rn Wfle.L
J
Name
Ll-,Jka, ,
' -"- 7
rom Iocallgn)
MA
Telephone Number
B. Pumping Record
1, Date of Pumping ------
Gallons
12S—--------- 2. Quantity Pumped�
3, Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank C1 Grease Trap
F Other (describe) -----------------.,------- ------ -------
4. Effluent 'Fee Filter present? 0 Yes o If yes, was it cleaned? Ej Yes [] No
5 Observed condition of component 1-.)wreed:
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6. System (lumped By
Dave Tine Mass IAA95E M s 1 A D-3 Z
—__ L _�
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Name
Vehicle, License Number
Baieson Enterprises, In(,,,
company
. hon where contents were disposed�
I (31-5DI
Signature of Hauler a(e
Signature of Receiving Facility (o( attach facility receipt) Date
15lorm4.doc. 11112 System Pumping Record Page 1 of 1