HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 180 GRAY STREET 9/17/2025 Commonwealth of Massachusetts pawnOf
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System Pumping Regard 1 2025
Form 4
Health P
DEP has provided this form for use by local Boards of Health. Other form cg but thn
information roust be substantially the sarne as that provided here. Before using thi, eck with your
local Board of Health to determine the form they use. The System Pumping Record roust 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 ba f sideF rig r lht
A. Facility Information BUILDING: front B`rrck side rear left: right
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B. Pumping Record
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1 Date of Pumping __... ._� . __._. _.. ?_ Quantity Pumped: �
Date Gallons
3. Component: [] cesspool(s) ( eptic Tank ❑ Tight Tank ❑ Grease Trap
[ Other (describe): __._ _------____. _
4. Effluent Tee- Filter present? ❑ Yes �—o. If yes, was it cleaned? ❑ Yes No
5. Observed condition of component purnped:
6 Syst 1 LlUmped By r \
(7a e l lney ------..__ _ _. .-_. Mass 1AA95E Mas 1AD31L
Harr ._„„._.. Vehicle License Number
Bateson Enterprises, Inc.
Cornfrany
7. Location where contents were disposed:
___---
Signature of Hauler Date
Signature of Recelv(ny Dater
t5form4,doc- 11112 System Purnining Record • Pagc, 1 of 1