HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 380 SUMMER STREET 7/30/2025 Town
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Commonwealth of Massachusetts -' rw/U�ver
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��xx��u� Pumping
Record ~ ~ �v��
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Form 4 Health D
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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 mr other approving authority within 14 days from the pumping date in
accordance with 31OCK4R15.351.
A~ Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
38O Summer S�mmt
ueeun�����
key»u move your Address
uvmo,-do not
North MA O1845-5G38
use the�tum
key. City/Town State Zip Code
2. System Owner:
^---� JamoaSca|ioi
Address(if different from location) .........
own State Zip Code
781'316-8787
Telephone Number
B. Pumping Record
7/3OC2025 1500
1. Date ofPumping 2. Quantity Pumped: Gallons
3. Type ufsystem: Cesspool(s) Z Septic Tank Fl Tight Tank R Grease Trap
LJ Other(describe):
4. Effluent Tee Filter present? Yes Z No |f yes, was itcleaned? Yea Z No
5. Condition of System:
Good system o dproperly
G. System Pumped By:
Jason Elliott S71437orV85257
wame Vehicle License Number
|veetorand Elliott Services LLC-DBAJaann
Elliott Pumping
7. Location where contents were disposed:
(�L�D
7/30/2025
Date
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