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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 169 GRAY STREET 10/24/2025 Commonwealth of Massachusetts Town of N01th Andl,,�,4 City/Town of System Pumping Record OCT 2 4 2025 Form 4 DEP has provided this form for use by local Boards of Health. Other,forms may e c information must be substantially the same as that provided here. Before using this form, check wit 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. HOUSE: front back lde>ear left rih A. Facility Information BUILDING: front back side rear left right Important: When DEC[(: under filling out forms 1, System Location: on the computer, w use only the tabd � key to move your Address cursor-do not use the return .._.._.____ . -_...._. __._ —__ M�' �_..___._..--____ Y ka City/Town State Zip Code fw 2, System Owner: _ �,q !Name Address(if different from location) MA Cik /Town --_Zip_. ______. Y State Code C " Telephone Number B. Pumping Record 1. Date of Pumping - 2. Quantity Pumped: --- X bate Gallons 3. Component: ❑ Cesspool(s) Septic Tank E] Tight Tank ❑ Grease Trap ❑ Other (describe): _.__ ____-----_. __._-___—__. ..�._.___-----__—_.�__._.,_._ 4. Effluent Tee Filter present? ❑ Yes z No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6. System Pumped By: DaveTlney _Mass 1AA95f Mass 1AD3T Name Vehicle t_icense Nu Bateson Enterprises, Inc Company 7, a ion where contents were disposed: GLS. _-..__ _. _ _.__ -- Signatur©of Hauler Date __.._ ________-_-_-._ __.__--__..._- ...._. Signature of Receiving�aeiliry(ar attach facility receipt) Cate — "-"- t5form4.doc• 11/12 System Pumping Record-Page 1 of 1