HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 580 WINTER STREET 11/25/2025 Commonwealth of Massachusetts
cr City/Town of _
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 same as that provided here. Before using this form, check with your
focal 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, __.__—________ ®r�n
back side rear.......-left ripfiA. Facilit Information BUILDING. back side rear, left right
.
y f;ht
Important:When DECK: under
filling out forms 1. System Location
on the computer,
use only the tab
key to move your f�ddrss
-do not MA
use th
use the return _______.._._. _......_. _-- -- _. _,.«„� .._
Cit Ci"own
key. Y State Zip Cade
2. S t Owner:
114re5
. V6%�t(............ —--------
Mme
reurn
Address (if different from location)
MA
_.
C �J
rty(T awn late
--- - -.
Telephone number
B. Pumping Record
1. Date of Pumping - atn_ / -,
-(.._lj_s Quantity Purnped; ail —
ons
3. Component: ❑ Cesspool(s) m eptic 'Tank htTank Ti
g ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes �No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of comp ept pumped "
5. Sy em PuVped By: .w.
D veTlneY-_____.___.__-__..__..___. .---------_-_--- _Mass_1AA_95E ass 1A{ 31
fJa e Vehicle License Nu er
Batdson Enterprises, Inc
Company
Location wh7 conte
nts were di posed,
GLSD
5i lure of Hauler Date
Signature of Receiving facility(or attach facility receipt) Cate
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