HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 79 VEST WAY 8/20/2025 Commonwealth
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Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must ba 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 318CPWR15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 79Veo VVu
key to move your xuumoo
cursor-do not
North MA 01845
use menuum
key. City/Town ~`~`^ Zip Code
1 SymbamOvvner:
~---~ Karen Manning
Name
ress(if different from location)
978-815-52U7
telephone Number
B. Pumping Record
8/2U/2O25 150O
1. Date of Pumping 2� Quantity Pumped�
3. Type ofsystem: Cesspool(s) Septic Tank Tight Tank Grease Trap
LJ Other(describe):
4. Effluent Tee Filter present? Yes No |f yes, was itcleaned? Yes No
5. Condition ofSystem:
Good, system operatingproperly
S. System Pumped By:
Jason Elliott S71437 or V85257
Nam-e- Vehicle-License Number
|vester and Elliott Services LLC-DBAJason
Elliott Pumping
7. Location where contents were disposed:
{SLSD
8/20/2025
Signature of Receiving Facility Date
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