HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 365 CANDLESTICK ROAD 10/16/2025 own
of Ivodhnever
Commonwealth of Massachusetts OCT 16 202
Comity/Town of
Health Dep9rhelt
y System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the sarne 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 -- __ ___---..__ _ .-},s�`
nt
A. Facility information BUILDING: front back side rear left
Important;When
DECK.: under
felling out forms 1. System f acat
on the computer, /- �� �
use only the tab — lam,_—_
key to move your Address
cursor-do not / MA
use the return _... . _.._".--"- _ _.._.
key.
City/Town Mate `—____�— ___ Zip Code
(� 2. System owner:
Name
Address (if different from location)
"_._�—__.._..._.__
MA
City(Town State -
Telephone Number
B. Pumping Record
1. Date of Pumping -.._ __. __.---.._ 2. Quantity Pumped:
D e
at Gallons
3. Component: [ Cesspool(s) Septic Tank Tight Tank ❑ Grease Trap
[� Other (describe):
4. Effluent Tee Filter present? ❑ Ye, If yes, was it cleaned? Yes ❑ No
5, observed condition of co 7ponent pumlFd:
6, Sy tem Pumped By:
D ve Tlne Mass 1AA95E Mass A631Z
tJa Vehlcle License Nun her r
Bateson Enterprises, Inc.
Company
7. i_ atlon e contents were dl., fj:
SD
signature of Hauler Date
Signature of Ftecelving Facility(or attach facility receipt) Date
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