HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 315 CANDLESTICK ROAD 10/24/2025 Ur
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Commonwealth of Massachusetts OC7
2025
City/Town of
- Systern Pumping Record HOalth
� x Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information r-nUst be substantially the same as that provided here. Before using Phis form, check with your
local Board of Health to determine the form they use. The System Purnping Record must be submitted to
the local Board of Health or other approving authority within 14 days from -.he pumping date in
accordance with 310 CMR 15.351 ------___
HOUSE fror back side - ea I&
A. Facility lnforlrnatlorl BUILDING: front knack sine rear left right
Important:When [BECK: under
filling out forms 1. Systern Lo 'at' n t
on lire computer,
u
se only(h e (a b �� I ------ --- _._-_.--------
- -
key to move your AddrOss
cursor -do no( NIA
use the retuu __ -- — .� -- _._
key. Ci(y/7own Stale------- ----- Zip Code - -------
2. Sy terr-i Owner:
` Narne -
learn ' _._ _._..—_ -......-...._.
ACSdross (II di(Yr,renl from location}
MA
cilWfo n si --- - ___._
Lip Code
TeI n Nun e
B, Pumping Record
1 Crate of Pun-tping -Da-� ___-.. __------- 2, Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank [] Tight Tank
g ❑ Grease Trap
❑ Other (describe):
4. EPfiuer7t Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes [� No
5. Observed condition of component pumped
6. Lave
m k Limped By M
TInF Mass 1AA95E ass 1AD31Z
_ Y Vehicle Ucense Number
or) Enterprises, Inc.
Company
-- _
71 L Cation where contents were, disposed:
�m.
signature of Hple e Dale
Sfgnalure or Receiving Facility(or attach facility (eceipt) Date
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