HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 485 FOSTER STREET 7/24/2025 Commonwealth of Massachusetts Town
4f o h
u�. City/Town of
=-- System Pumping Record 1 , 2025
Form 4
DEP has provided this form for use by local Boards of 1-je11th. Other forms rn`'T
information must be substantially the same as ihnt provided here. Before using this form, c�e'clFwith your
local Board of Health to determine the form they use, The System Pumping Record musl be sut, mitteo 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. ----_ -----___-_-- _---__-----__--
A. F�C1�1'�� �t1�Orrn��lOr1 _....... .......--.__._ BUII�DSNG�. front back side rear _-_
ft r if�f
y rear lefi rif ht
Important: When DE('K: undP,r
(filing out forms 1. System I_ocahcn:
on the cornpuler,
use only the lab � � -
key to move;your Addr
cursor -do not _ - - -
use (he return n
key. C.it /Town M p Code
r 2. Sys ern Owr er
N a fn H
Address(If different from location) v -- - — ---__�_._----------- — -_--
MA
Clty/TOWn SIale Od P,
elephone Nurnber
B. Pumping Record
1. Date of Pumping Gate -- — -- 2. Quantity Pumped: ---
Gallons
3. Component: ❑ Cesspool(s) Septic Tank Tight Tank ❑ Grease Tray
Other (describe): --- --- -- ---
4, Effluent Tee Filter present? ❑ Yes [_ r!o If yes, was it cleaned? [_] Yes [) No
5. Observed condition of component puree
6. Sys mlay
Gjmped By:
Q ve TI � I,,/ Mass 1AA95L M ss 'T-A 31Z
ame VeNcle License Nurnber
Company
7. Locativ where contents were disposed:
Signature of Hauler Oate
Signature of Receiving Facility (or attach facility receipt) Cale
Worrn4.doc, 11112 Sys l em Pumping Record page 1 of 'i