HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 149 BRIDGES LANE 8/5/2025 Commonwealth of Massachusetts down 'Of"'th AndOVer
City/Town of AUG 12 2025
System Pumping Record
Form 4
Health De
DEP has provided this form for use by local Boards of Health. Other forms My Nrtalerat the
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 or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 16.351.
HOUSE: front backside re d�,J.4t—right
BUILDING: frontqlack side rear left right
A. Facility Information DECK: under
Important:When
filling out forms 1. System Locatipn:
on the computer,
use only the tab ) L�
key to move your Address
cursor-do not MA
use the return
City/Town Zip Code
key.
2. Syst m Owner:
'Nam
Address(if different from location)
MA
CityCT`own State Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. (Quantity Pumped:
Date Gallons
1 Component: ❑ Cesspool(s) IDISeptic Tank 7 Tight Tank 7 Grease Trap
0 Other(describe): -----------—
4. Effluent Tee Filter present? ❑ Yes [3-�Nlo If yes, was it cleaned? F Yes ❑ No
5. Observed condition of compon nt pumped:
6. stem Pi�v q ped By:
ave Tine Mass 1AA95E M LssIAD314____
ame Vehicle License Number
LB n Enter..E�es. Inc.
Company
7. ca ion here c tents were disposed:
Signature f uler
Signature� of Re'ci�flving Fac:�M�(or attach facility receipt)--.--`-- Date
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