HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 675 FOSTER STREET 9/10/2025 Town of*0
Commonwealth of Massachusetts der
City/Town of _ SP
19 System Pumping Record 225
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Farm 41$ 3 "
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DEP has provided this form for use by local Boards of Health. Other forms may be uu�t1, but 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 15.351.
----_-___ MOUSE: front aZk side c left &i
A. Facility information BUILDING: front back side rear left ii`li�T 1
Important:When DECK: under
oiling out forms 1. System Location,
on the cornputer, -� �`
use only the Cab --- _ _ ❑�l �..._ .
key to move your Ad( es _
cursor-do not tytl'own -� __ _ __ ._...___. ,MA�e___..____._... _ __.._.--
use the return C __ Y' a"':,.. - 7 p ode __----__. -
Key, �-
2. a r Owner:
III,LIZI
�'� Name
/NU71❑ I
Address (if different from location)
MA
City(Town State Zip ode _ _.. . ...
telephone Number
B. Pumping Record
1. Date of Pumping ._ _ ___._-- 2 Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) peptic Tank Tight Tank ❑ Grease Trap
[] Other (describe): _._______
4. Effluent Tee Filter present's ❑ Yes [ o If yes, was it cleaned? ❑ Yes ❑ No
5, Observed condition of component pumped:
.........._
6. Syst Pumped By:
Dav i lr7e}4
Mass 1AA95E Mas 1AD31Z
Nam Vehlrle License Number
Bateson Enterprises, Inc,o_m_p
Company
7. Location where contents were disposed:
Signature of Hauler Date
_._ __r.__.—__ ;.-�—__. .._...___ _.. -------------_
signature of fteceiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 Systern Pumping Record -Page .i of 1