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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 32 CRICKET LANE 11/25/2025 Commonwealth of Massachusetts � City/Town of System Pumping Record N ' t 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 file foorn They use The System Pornping Record must be submitted to the local Board of Health or other approving aulhority within 14 days frorn -he purnping date in accordance with 31 D C M R 15,351 HOUSE front back ,ode rpa lef ig A. Facility Information BUILDING: front ack side rear left rig! Important;When DECK: under filling out forms 1. System Location on the cornpuler, use only the lab -._ key Io rnove your Address - - cursor - do not MA use i h e r e t u r rr ..__. —---- --- -- ---- -- ---- ---- key CIIyfTown Slate Zip code Z System Own ; fir Name -- AUdr©ss (il rJifi4re� l from location) MA C11y/Town 51a(e Zlp Code - - Telephone Number B, Pumping Record - ----- 1 Date of Purnping -_.�� '._-- 2. Quantity Pumped' -- - - -----_ dale Gallons 3. Cornponent. ❑ Cesspool(s) F41xeptic Tank ❑ Tight Tank ❑ Grease Trap Other (describe): 4, Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes [] No 5 Observed condition of cornponent purrtped G ysterr �'I, raped By � Dave T i n e Y ------------ --.-_ _ Mass 1 AA 9 S E M s s 1 A D 3'1 Z Name Vehicle License Number - B2ale n E_Merprises, Inc. 1pany 7 ;anon where contents were disposed .y. --- -- —- _ .__ - - - _ --- ------- "Ignalure o Hauler Date Sf ---.. ---- ,_-- --- --.___... gnalure of Receiving Facility (or aflach fa iii(y receipt) Dale 1510rm4.doc, 11112 System Bumping Record Page 1 of 1