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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 66 EQUESTRIAN DRIVE 10/27/2025 TO Wn Of JVCrtl�j noVer Commonwealth of Massachusetts OCT City/-Town of za25 System Pumping Record Ileath -- Forrn 4 a "1pyt DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the sarne 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 from the pumping date in accordance with 310 CMR 15.351, — -— ---_-------- 0. I e HOUSE: front a {�1 side re a r.� right: A. Facility Information BUILDING: front back side rear left right Important:When DECK: under fllling out forms 1. System Location. on the computer, f /� use only the tab key to move your Ad ress �r f cursor-do not {/'�/J (`fp^ ✓ MA use the return key. Cityffown state Zip Code 2. Sy tem,Owner: J Name Addrrsss (if differ©nt from location} MA City/Town state j� ( Lip Code 7 e- 1_ —` -- - - -- -- Telephone Number B. Pumping Record 1. Date of Pumping ---- -� � -- 2. Quantity Pumped. Gate Gallons 3. Component: [] Cesspaol(s) 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 companen pumpeed:: & Syste l Pumped By'. u..,... C7aveTln y _._ MasS 1AAg5E ass JAD31Z NarY7e Vehicle License Number � Bateson Enterprises, Inc. Co —_-- .- - — Company 7. Location where contents were disposed: Asa .w Signature of Hauler Date Signature of Receiving Facility(or attach facili y receipt) Date - t5form4.doc- 11112 System Pumping Record •Page 1 of 1