HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 116 CHRISTIAN WAY 9/11/2025 _
Commonwealth of Massachusetts n of Ir�AnOv
er
r City/Town of
x System Pumping Record SEP 9 2025
e, Form 4
e /t
DEP has provided this form for use by focal Boards of Health. Other forms mailPe� the
information must be substantially the same as that provided here. Before using this formf�th 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. --- __.
HOUSE: fron acki sid r le.ar�� right%
A. Facility Information BUILDING: front back side rear left right
DECK: under
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filling out forms 1. Sy LOC tiQfrl: ,+y
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use only the tab U
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use the return __—^a.__
key. City/fT'own State Zip Code
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Address(if different from location)
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City(Town State - Za�(ode
Telephone Number
B. Pumping Record
1, Date of Pumping --- ---- ------- 2. Quantity Pumped: __.._.-..._..._.........
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe);
4. Effluent Tee Filter present? ❑ Yes a If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. [Bvte �
em Pumped By:
7ey Mass 1AA95E Mas 1D31Ze Vehlcle License Number on Enterprises, Inc.
Company
7. Lac`atjon re contents were disposed:
`IW V r..1 � ...-
w
Signature of Hauler Date
_..._ ._.___________ ;-- _..__ i l i
Signature of Fteceiving Facility(or attach facility receipt) Date
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