HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 326 FOREST STREET 11/14/2025 Commonwealth of Massachusetts I U W17 Of North 41760 Ver
City/Town of A10 V 14 2o25
System Pumping Record -10c
Form 4 DepartM,,,t
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 CIVIR 15,351,
HOUSE: lront�)baclk side rear eft fright
A. Facility Information BUILDING: �16-nt back side rear dzl' right
DECK: under
Important:When
fililng out forms 1 System Location:
on the computer, C-?use only the tab
key to move your Address
cursor-do not MA
use the return City/Taw-- ..n State Zip Code
Key
t ,
I LO2 2. Sy tern Owner)7 ; � q , -- -o x — . I---
.. .j --L ......-----
Name
Address(if different from location)
MA
CltylTawn State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3, Component: Cesspool(s) D-18eptic Tank 7 Tight Tank 7 Grease Trap
❑ Other (describe);
4, Effluent Tee Filter present? D-"Yes ❑ No If yes, was it cleaned? Z,`�e`s ❑ No
5, Observed condition of component pum ed,
6, stem P. roped By:
ve in Mass 1AA95E M-ss I A D 3 1
Vehicle License Number
Bateson Enterprises, Inc,
Company
7, ation where co tents were disposed:
L§ --------------
-§lTr�aiu' re of Hauler 'Date
Signature of Receiving Facility(or attach facility receipt) Date
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