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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 104 SHERWOOD DRIVE 7/24/2025 Camrnanwealth of M � =� Taw��f wsachljsett �011 r r City/ l. �l own of q�dp�, System PurrPiri --- Record AUG Form 4 z DEP has provided ibis fornn for use by local Bw-Ards of I-icajlh. O('her form, rr�ay t)u�`� 11 the information must be substantially 11)e same aS that provider] hE�are. E;efon=� rasing ibis form, � U7 youn fo of theallo(calaBoard lofdHeaith determine a[he pp-o vinglaulho(i use. ty wolf iny114 drays from the pumping d t�r�lsu4�7rlitlr°c1 to nr„ Record ping dale n accordance wllh 310 CMR 1s.351 ___----- _-_-- HOUSI: front ack side rear lef npht A. Facility Infofr`T1atloll BUILDMG'. franc back side rear ieft IL mportant:Whor, DECK: under 011lncg out Iorrm 1. Systern Location on(he c, mpulpal, lC��^ use only 010 lab Qrwgp r key Io rnovtY your Address rnsor do no,l j ( c r Lisp. tie (olurn 1 SI_...--- .-- MA key. City�l'own stale; — ---------- Zip Code -- — 2. Systern Owner - - Lf N 81'rl G'Vn ./ Address (9f dlfierorrt from IocaUon) Y f� 1 a I �+r?._{J Zip Code V _ T---elephhoonnee Nuu— mbe —%--- R ----- r B. Pumping Record r 1. Date of Pumping ba-IP �25 _ _. -- 2. Quanwy Purnped Gallons 3. Component: ❑ Cesepool(s) Septic -lank [._� Tight Tank ❑ Gr©ase Trap Other (describe): __.-_--- 4. Etflucnl Tee f-ilier present7 _� /,nped: (_� Yey es, v�ts� it cicvGan�,d"> _� Yes C�� No 5. Observee condition of cornponent p 6. Systern Pufnped By: Dave Tfney-- - ----- --- --- M7ss 1 AA95G ass AD31 _._.. IVBn'1e A/et�IclE l.icensr; f�JumbPr Ba ew FnfWprisPs Inc Gornpany 7, Location where contents were disposed. LSC Slgna of Nat.aler Ua1t, - ----— - -: - -- - _ .------ Sl�nalurs of Recelvintl Facility (rut a0ach fscilly reccipl) Dale ---- _. E(crm4.doc' t1112 Sys(er)Pumping pecogl r)>Jte t Or a