HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 370 SUMMER STREET 12/23/2025 =� Commonwealth of Massachusetts
G;
City/Town of
. n
"A� System Pumping Record
Form 4
DEP h2s provided this forrn for use, by local Boards of Health. Other forms may be used, but the
inforrnatlon must be, substantially the same as thsat provided here,. Before using this form, check with your
local Board of Health to detern,�tine they farm theey use The System Pumping Record rnust be subrnitted to
the local Board of Health or other t-lpproving authority within 1 el d,'ay s from the purnping date in
accordance with 31() C.;IOR 15 i 51 -
-0US1 : fronj front back rear ,.,! r pf'It
A. Facility Information BIJll_c71NGS � t right
Important: *hen
E:t::i<: t.a re,ei r_'r
flihng out farms 1. Systern Loccalic—W
on(!le Cornpulef, �'',",�✓�°
,ise only 1ho (ah ..1-.-..-..._� _.. tom' ....... ,
key to move,yczur Adu'"f ss
cursor-do nol (p MA
use tt,e return _ .._.._.._�.., --1�-� "4� ........ _._---...._.. __-__... --------
key
C;iC flown __._..__ ... ...._.._-.
Y �f£a(e lip Conic
') 2 S stcerr1 Owner:
Ns,me
_..___. Andress (if ditferenr frorn location)
MA
Owf) JI 71f: ... /IO cod _...... ......
cirphvnc. Nurnbr:I
B. Pumping Record
I Cute of Pumping >, Quantity Purnpc d
OaIe Gallons
3 Component (- cesspool(s) � ,•S tic (r.3rrk
p ❑ Tight rank Grease Trap
�__} C>th r (riescrll7 }
11, Effluent ..Fee Filter present? F-j Yes h1�ca If yes;, was it cleaned? Yes [_.) t,4o
g. Observed condition of cornporle pe.rrnf,ed
✓ U
Syvt� rfa�a,rl�pod By
Mass" tAF�,95E M ss
__
Vr.trVt;lu 1.ic,urrSt'. Nurrr15E.r
E t sin f nfESrprises, Inc.Cornpany
I Lol,alion whe? ea Contents were
ignaturo of V it+ulC;r t.)<atn
�1 .d ilfCy (car lrli�r,t� (rrcili(y �<�cc;p�...
--—
C,nb,lure of F�e,c.e?Ivint f=�c 1) Date ---- - _
t5forrn4.doc• 11112 System Pur'nping r:,Corr,1 f�r�n tr;�, 1 cN 1