HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 124 STONECLEAVE ROAD 8/11/2025 Town of A
Commonwealth of Massachusetts Northnao Ver
NrrCity/Town of
AUG 122025
System Pumping Record
Form 4
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DEP has provided this form for use by local Boards of Health. Other forms may be us I
information must be substantially the same as that provided here. Before using this form, check with your
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 16.351. —
HOUSE: front side rear le right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your -Address
cursor-do not MA 0 1
use the return City[Town State Zip Code
key.
2. System Owner:
Name
-Address(if different from Ioc-at`lon—) "------
MA
ty/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: 7 Cesspool(s) Septic Tank 7 Tight Tank ❑ Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? [I Yes No If yes, was it cleaned? F Yes F� No
1
5. Observed condition of component pumped:
6. System Pumped By:
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Name Vehicle License Number
Bateson Enterprises,
do-mpany---
T. L where contents were disposed:
(G L S§MD --------- ......
Signature of Hauler Date
-'Signature of Receiving"Facility(or attach facility receipt) Date
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