HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 140 CHRISTIAN WAY 9/5/2025 Commonwealth of Massachusetts Of lVorth Ver
OW
City/Town of
System Pumping Record SEP 19 2025
Forrii 4
DEP has provided this f0i'M for Use by local Boards of Health, Other forad but the
info(r-nalion n-iust be substanlially the sarne as lhat provided here. Before using MQji, check with your
local Board of Health to deterr-nine ihe form finey use The Systern Pumping Record must be submitted lc
(he local Board of Health or other approving authority within 14 days frorn she purnping date in
accordance with 310 C M R 15,351 -- —------
HOUSE: front <571< 5�K-r-e`ar ,deft t
A. Facility Information BU I Li front back side rear left
Important;When DECK: under
(Ming oul Iofn)s I Sysli Locai
on the cornputaf,
use only the tab
Rey to rnove your Aoofes5
cursor do no(
use thereturnAJ &N'A,0/ M A
k e,y, ty/-rov, State Zip Code
2. Sysi Owfler
Narne
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Address (it dii from location) -
MA
Town Stale Zip Code
Telephone Number
B, Purr [Ding Record
f, Date, of Purniping Gallons
-a t u 2 Quantity Pumped'.
3, Cor-niponent. --S'�Pnc,-rank Grease Trap
-1 Cesspool(s) Tight Tank
L-1 Other (describe) ------
el, Effluen( -Tee Filter present? [] Yes No If yes, was it cleaned? ❑ Yes No
5, Observed condition of cornponeni pumped
vo
6, System By
Dav > line Mass 1AA95E Mass(IAD3'1/
Vehicle, License Number
BN,eson Enterprises, Inc
-cror nf)a i y
7 _rI)i.ornwhere contents were disposed
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Signatufe of iiaule( Date
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System flurrii Record Page 1