HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 222 BRIDGES LANE 10/25/2025 commonwealth of Massachusetts oWn Of IVOrtl 11dover
City/Town of
System Pumping Record OCT 2025
Form 4
ea/
DEP has provided this form for use by local Boards of Health. Other forms may `
information must be substantially the sarne as that provided here. Before using this form, chec (th your
local Board of Health to determine the form thoy 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. ----- ___. _._.. .... ..
HODS<�nt,_;-b;ack side rear leftc'rlki�.:'r
A. Facility Information BUILDING: front back side rear left right
Important;When
BECK: under
Mling out forms 1. System Location.
on the computer,
use only the tab ',G
key to move your Address _
cursor-do not
use the return
key. city/Town State Zip Code
(} 2. System Owner:
ILI
/J Name
(II _J 2'�
Address (if different from location)
MA
Gifyffown State Lip Code
er
B. Pumping Record
1. Date of Pumping -- - 2. Quantity Pumped:
Date Gallons
1 Component: Cesspool(s) ti Septic Tank ❑ Tight Tank ❑ Grease Trap
Other (describe):
4. Effluent Tee Filter present? ❑ Yes ( No If yes, was it cleaned? ❑ Yes [� No
5. Observed condition of cornponent umi�)ed:
—---------
__._-.__
6. System Pumped By:
DaveTlne Mass 1AA95E 'Mass 1AD31��
Name Vehicle License I ber
Bateson Enterprises, Inc.
Company
7, ocl�tion where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt} Date
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