HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 145 COLONIAL AVENUE 10/16/2025 "VI U 1 Ml MUM[
Commonwealth of Massachusetts OCT 16 2025
City/Town of
System Pumping Record Hco jtlj Department
Form 4
N
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.
right
HOUSE: ,back side re�) 16
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Locltion:
on the computer,
use only the tab
key to move your Address
cursor-do not MA
use the return
Rey. CityfTown State Zip Code
2. System Owner:
�Y L� ] -------
Name
Address—(If—different-from location)
MA
Zip Code
stat,
-telephone Number
B. Pumping Record
2. Quantity Pumped:
1. Date of PumpingDate Gallons
3, Component: ❑ Cesspool(s) L-31Septic Tank 7 Tight Tank 7 Grease Trap
❑ Other (describe):
4, Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes [] No
5. Observed condition of compone t pumped,
6, System Pumped By:
Dave Tine M@sslAA95E Mass 1AD31Z
Name Vehicle License Number
Bat,es-66 Enterprises, Inc.
pany
T Location wh6re contents were-rli-s-po- ed:
GLSD
------------
-----------
ignature of Hauler Date
Sig-ria—tu-r—e"-o-f--R-e--c,eiving Facility(or attach facility receipt) Date
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