HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 151 STONECLEAVE ROAD 10/24/2025 -
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System Pumping Record OCT �
Form 4 -^ ' �� ��rr
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DEP has provided this form for use by local 111 but the
information must be substantially the some as that provided hare� �e check with your
|oCe| Board of Health ho determine the form they use. The System Pumping R��� PAtst be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31OCMR15,351
HCUSE: front C�acl')side rear left
A. Facility information BUILDING: front b'a-c—k side rear left right
Important:
under
�n��When �
filling out forms 1. System Location:
on the computer,
use only the tab '
key mmove your *uureou
cursor'do not
MA
vaeme,emm —
key. City/TownState _- -_-
Of
2, System Owner:
Address(if different from location)
MA
Qty�Tnen State
Zip Code
T�lephone Number
B. Pumping Record
1. Dote of Pumping ' 2Date � Quantity Pumped�
Gallons
3. Component Cesspool(s) Dt 1-71
Septic Tank El Tight Tank [I Grease Trap
[] Other (describe):
4. Effluent Tee Filter present? 7 Yes L4 No If yes, was it cleaned? F Yes Fl No
5. Observed condition of component pumped:
/
8. System PWmped By:
DaveT|ne
Name Vehicle License Number
B3temon Enber i |n
'
Company
7. Location wheredisposed:
—44
Signature of Hauler Date
t5fonn4.um, 11n2 System Pumping Record ^Page 1of 1
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