HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 41 NORTH CROSS ROAD 9/16/2025 To no o h n
Commonwealth of Massachusetts t lover
F City/Town of
a stem Pumping Retard SEP 1 9
Y p g �025
S
= u 4 Form
r
gall-
DEP has provided this form for use by local Boards of Health. Other forms ma ,t -t
information must be substantially the same as that provided here. Before using this farm, c``� ,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 313 CMR 15.351. ------.-__.- ..
HOUSE: front Pa,c'k side reaa'+ left i htl)
A. Facility Information BUILDING: front back side rear left ripr,t
Important;When DECK: under
Cation;
y
the tab
(tiling out forms 1, System
4�1`mo �
on the computer,
use onl i
key to move your Address
cursor-do not
use the return —----- — - -- . :". .__ ----
key.
CityfTown State Zip Code
2. System Owner:
(1 Name - -. .. ... ._ _.._.
rNan L, yV
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
Date ( �
1. Date of Pumping 2 Gallons t_,a�
---_-"-p._ _.-----______.__---- Quantity Pumped: ��------------------_
3. Component: ❑ Cesspool(s) E]/Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): - ______ ------_.-----___------------___�___---
4. Effluent Tee Filter present? ❑ Yes n No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
G� C
6. Syst Pmped By:
D veTln� —_- Mass 1_AA95E -- ass 1A 31Z --_
-- - ---- -.___.---- --
N me Vehicle License Number
Bateson Enterprises, Inc.
Cot7ipany
7, ocation where contents were disposed:
sts� - -
-------- — — — ---- __ 16
Sig
__eb—au Date �* _-..__— --------- - --
Signature of Flece,ving Facility(or attach fac,lity receipt) Date
t5form4.doc• 11112 System Pumping Record •Page 1 of 1