HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 96 FARNUM STREET 11/14/2025 1VOf nth
Commonwealth of MassachusettsAtoV 14 20�
City/Town of °�
n System Pumping Record e t
= Form 4p
DEP has provided this form for use by local Boards of Health. Other forms may be used, but 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 from the pumping date In
accordance with 310 CMR 15.351
NbUSC; front Q2c side rear left right
A. Facility Information BUILDING: front back side rear left right
Important;When
DECK: nder
Ailing out farms 1. System Location,
on the computer, �`/" r""
use onlythe tab ( � �°'t
key to move your Address
cursor-do not
use the return .._.___. - ...___.._.___ .. __.—_.. _._...__.. _M`�
key. CitylTown State Zip Code
/1 2. System Owner:
ILI
r C .-
Name _
4 Address (if different from location)
MA
___._____.__..._._._ _.-. .-______________._._._._ .__.... _____.._.__._.-- _.._.___...__ ..__.......
CityrTown State Zip Code
telephone Nurnber
B. Pumping Record _
1. Date of Pumping ___jls� .____ 2. Quantity Pumped
Date Gallons
3, Component: Q Cesspool(s) Septic Tank ❑ Fight Tank [ Grease Trap
[] Other (describe). -..___._.---------
�__/__—_v ------ __- _--------._.-_-___
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tlney __._._._ _-_- Mass 1AAg5- Mass 1AD31Z
Narr7e n s e, Number
Bateson Enterprises, Inc.
Carnpany _.
7. L , tion where contents were disposed:
GLS
Signature of Mauler Date
Signature of F;eceiving Facility(or attach facility receipt) Date
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