HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 340 FOSTER STREET 8/1/2025 I TOWn aft Oqh An,'!L\. Commonwealth of Massachusetts
City/Town of
System Pumping Record AUG 12 2o25
Form 4
DEP has provided this form for use by local Boards of Health. Cit"'ths us
ln"tg�but the
information must be substantially the same as that provided here. Before W'eck 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
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A. Facility Information BUILDING: front batk side rear left right
DECK: under
Important;When
vise
ng out forter
s 1. System Location:
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key to move your Adores
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use the return City[Town (State'." Zip Code
key.
2. Sys rn owner:
Name
Address(if different from location)
NA
CitylTown Zip Code
State „(-'/ d 1�/� q, (/2
-Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Lallans
3. Component: ❑ Cesspool(s) 2-t-eptic Tank F-1 Tight Tank 7 Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? 7 Yes D—No If yes, was it cleaned? F Yes Fj No
5. Observed condition of component umped-
6. stem Pumped By:
ave Tine Mass 1AA95E M s 1AD31Z
ame Vehicle License Number
B esoh'Enterprises,-Inc.----,------.--.--,-,--
Cdmpany
7. �Lrrcatirn where contents were disposed:
L S
Signature of Hauler Date
Signature of R—eceiving Facility(or attach facility receipt) Date
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