HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 15 NORTH CROSS ROAD 9/23/2025 Commonwealth of Ma a us � To�un ° NorthAndov+ r
ss ettu ch
City/Town of SEA 2 9 2025
� Pure ir7 Record
System
\ Form 4
Health Department
DEP has provided tht s form for use, by local Boards of Health. other forms f-nay be used, but the
information rnust be substantially the same as that provided here. Before using this form, check with y
local Board of Health to deterrnine the: form they use. The System Pumping Record must be submitter
e the local Board of Health or othef approving Authority within 14 days from the pumping dat
wccorciance with1U CMf2 15 3`f1 _. f7U�t _._._
C'111 Information IOf1 �l�It.DI� r-ran k�a �✓sir
T A. Facility ty o C IN front back sick rear Vef
DKK under
4
Important:lr ot f� ms 'I,. System Location:
on the e use only the
key to move your Address
u�>e the rc�turrr MA & ��
key Cityrf
State Zip Code
2. System Uwne
Naam
rerun ��C)
Acirir7, (ff d ffarer�t fro � 1 catipn)
MA
C,Ityffown State zLgy Code
fedephone Number
.__........
B. Pumping Record
1. Date of Purnping —. __ 2 Ouantity Pumped
alE; Gallons
3. Cornponent. � f cesspool(s) [ Septic 'Tank F-] Tight Tank C Grease .t_r,ar,
y E-7 other (descr'ibc )
4. BfflUent Tee Filter present? Y 2s (. �o If yes, was it cleaned? ❑ Yes [..] f�lo
5, observed condition of r ornponent pumped:
i`
6 S Pumped By.
ave TlneY fV1ass 1AA65E- fo ss 1A' 31Z
ar7e VehICIo L icon,,e, NUIT)`-e-,
Batesen Enterprises,s Inc
C r7mpany
l I-o ation where: contents were diSIDOSed
LSD _.
§ignak re of Hauler Date _—�--
, ilgrralwe of Rec,eivkiy f r3c!hty (cif attach fadhl y rr,.c ipt( Date -
t5forrn4.dc)c• 11/12 Syslem Pumping Record - Page 1
P