HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 51 HAY MEADOW ROAD 10/27/2025 �Ht Commonwealth of Massachusetts own Of rj`4t do
ver
City/Town of
_ OCTs, � system Pimping Record , 2025
Form 4
e. edit/
DE P has provided this form for use by local Boards of Health. Other forms n-layqp
nformation must be substantially the sarne as that provided here. Before using this form,"with your
local Board of Health to deterrnine the form They use. The System Purnping Record mLlSt be submitted to
the local Board of Health or oth e( approving authority within 14 days frorn -.1hP purnping date in
accordance wlti-i 310 CMR,, 15,351 -.-_
A. FacilityirlfC7rr1`ic`��IC7r1 BU�DINC�: front �ac�stc9e �r�96rv�t�f�
r —
ief. right
trnportant:Whee DECK: under
(filing out forms 1. System t.o 'c7tl0n:
on the cornpuler,
use only the tab
key to move your Addre s
cursor -do not fv1/A
use the return _ .. .-.__ .. ,. e... - - -- ---.. - - -----
key, Cltyrrowr7 Slate Zip Code
2, S y s t e(T) Owne,r
Name - _... __... ....-
Aodross (if different frorn location)
MA
_ __.
cnyrr0Wrl >l�l�
�i c ae
Telephone Number
B. Pumping Record
1 Date of Puntpincl ._ .. .-- _ .. .._ 2 Quantity f'um red'.
f.:7ale y E Gallons
3 Component. (-] Cesspool(s) ertic ark [� Tight Tank (-] Crease Trap
Other (desc;rilbe)
4. Effluent Tee Filter present? [_j Yes If yes was It cleaned? ❑ Yes [ } No
5. Observed conditiort of component pulped:
(3 `3y tc.n`. . n-lped By r
t
r1 Mass 1AA95E Mass 1AD31Z
V
a E , - - _._.._... ... _.._w..... - - - _. .. . . _._. .- --...- --
ehiClf._. CP.n__SE fVu ber
3�feseln Enterprises Ire(.
Cor7rrlr3n}r """"
7 Location wl-iere contents were dispc s,ed
LS[)
r�nati.lte of Hauler ( ---
:/
------------
Slgnaature of ke.ccwIn gracllil or a(aC faCiIiPy eceipt) Date
l5form4.doc- 11112 Systern Purnf ing Rerord Page 1 of 1