HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 34 LIBERTY STREET 10/24/2025 Commonwealth of Massachusetts To Wn 0 f IVOrth n do Ver
City/Town of
System Pumping Record ICT 24 2025
Forrn 4
DePa
DEP has provided this form for use by local Boards of Health. Other forms may be qr'q,qO' the
information must be substantially the same as that provided here. Before using this form, check with your
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 frorn -.he purnping date in
accordance with 310 CMR 15.351 —-—------------- ---------------
HOUSE. ( front ptack side rear I right
A. Facility Informatiot'l BUILDING: "MTront back side rear left right
Important: When DECK: under
filling out forms 1. System Location
on the computer,
Use only the tab
key to move your Address
cursor-do not MA
use the retuin
key, ciiy/-rowr) State Zip Code
2. Systern, Owner.
ILI
Name
-A�d(es—s (if—d i tf-e-—re—n i from------1 o-c;a- ho'n
MA
Clryfrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped. ix
Date Gallons
Component.. ❑ Cesspool(s) Septic Tank ❑ Tight Tank Grease Trap
O(her (describe),
4. Effluent Tee Filter present? El Yes If yes, was it cleaned? E] Yes ❑ No
5. Observed condition of co-nipon nt pumped:
'T'
6, Systen-) Pumped By�
Dave Tine y Mas41AA95E Mass 1AD31Z
--------------------
Nan)e Vehicle License Numb
Bak so n Enterprises, nc
Company
7, Location where contents were dispo,,zd-
G L5
7
- ----------
s ignalufe of Hauler Date --
(of attach (ncili(y recelipt) Date
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