HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 265 SUMMER STREET 9/17/2025 Town ®f adh Ando
per
i'-\ . Commonwealth of Massachusetts ��
2Q25
City/Town of
System Pumping Recordlolh
Form 4JpM
DEP has provided this form for use by local Boards of Health. Other forms may be used, 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. _--_ _— _ ------
— — HOUSE: font back side rear left rl
A. Facility Information BUILDING: front back side rear left right
Important: When DECK: under
felling out forms 1. System Location,
on the computer,
use only the tab . .--- :. - `
key to your Address
cursor do not �' �, MA
us -do e the return
key Cityffown State Zip Code
2. Sy4tewn r.
11 l --� Nam -��: -— ---- _-- -----
Address (if different from location)_
MA
City(Tow) State �y Z' Code
__ -------- --- .._.
Telephone Number
B. Pumping Record
1. Date of Pumping — __ _ __ 2. Quantity Pumped: ----1— -.___
Date Gallofis
3. Component: Cesspool(s) F eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): __--_--_____._._ ______ .------_ _-----__—.__.___--
4. Effluent Tee Filter present? [J Yes[] No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
6. Sy tem umped By:
D ve TI e Mass 1AA95E M ss 1AD31Z
_...__. .__.__y-_ __- -
.__--
Na-ne Vehlcle license Number
Bateson Enterprises, Inc.
------------------- _. -- ----------
Company
7. Loc lion whwere disposed:
- __..
Signature of Hauler
Signature of i2ecelving Facility (or attach facility ra,cr il�7t) Uate
t5form4.doc- 11112 System Pumping Record - Page 1 of 1