HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 80 SUTTON HILL ROAD 11/26/2025 r Commonwealth of Massachusetts
� u 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 Phis form, check with your
local Board of Health to cdeterrnine the form they use. The System Pumping Record must be submitted to
the local Board of I--iealth or other approvinr, autl-orlty within 14 days frorn -.he purnping date in
accordance with 310 GIVIR '15,351
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B, Pumping Record _..._._
Tele nr tJurnbar
1. Date of P:Iur ir7q u ate _.__ _- 2. Quantity Pumped.
Gallons
3. Cornponent. �u_] r esspcof(s) ] eptic 'Tank E] Tight Tank ❑ Grease Trap
Other (describe) __._.._._.__-- -.__-- __._...
4, Effluent Tee Filter present? Ej Yes rj Nc If yes was It cleaned? ❑ Yes [j No
5. Observed condition of c<arnpor enf pu-nperd.
5 steii unif e'ad By
ave i inF Masi, 1AA95E Mass 1J31Z
Varnr Vct7lrJr, Lice Num er
f3a �s�n E 17tEr��n��s.-fin(`
7 L Ca(i ) vt7,, .e contents were disposed
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Signatme of h abler Date
_... _ _
Ignalt�ru of here�iv6nq I <:,ciliiy (ar a���U�rcY) (�rGilsly rr�ceiral) Cate __..... _._.....__. _..
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