HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 314 CLARK STREET 12/18/2025 _` h Commonwealth of Massachusetts
a City/Town of
System Pumping Record
Form 4
DEP has provided this form for use by IOC21 Boards of Health. Other forrns may be used, but the
information must be substantially thr'., same; as that provided here. Before using this form, check with your
local Board of Health to deterrrrine the fornr they use The System Pun-lping Record must be submitted to
the local Board of Health or other approving authority within 1I1 days from the pur`nping d@te in
accordance with 310 CMS; 15 351 HODS[ : front ba�s d"e�t rear IF>
1' t
A. Facility Information BUILDING: front back side rear deft right
important: When DECK: under
(Ming nthy e o
unit forms 1. System
rTi f_.(aC<-ItlClrlr
e only
-:
Ad "�� ._ .. - — - --
Fy f move your dr
ess
cursor-do nol 41 ,n('�
usr�the return ___..____ ._ ._....... ._.. �_1_ _._ fJiA
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key, Cityli"own State Zip Gorse
y.
2. System Owner.
Name
((lMIdYPI Z (�
Address (if different frorn location)
MA
City(hown Nair / _. ...
f Trlr;rho �1 lir7 Cada�
r c t Ter
B. Pumping Record
1, Date of Pumping
p 9 2. Quantity Pumped
Gallons
3. Component: [ Cesspool(s) E],,�eptic 'Tank "Fight Tank 9 Grease Trap
Other (describe)
Effluent Tee Fitter resent? Yes
P �_.� [� . If yes, was it cleaned? C] Yes Elt4o
5. Observed condition of curr acn fit pumped.
6. ystem Pumped By
Mass 1!'rl�915E- Mass 1AD31Z
_ O/ _ __ _.
hlrar'r�e VehPr„Ie l_irense,• Nurr 7r�,r
(-B-ate<n C"nterprises Inc.
7. Location whey. ontents were disE-�orecj
Cal SU _
_ _ ..
_iutrradr.ilrs o Fm pr f5ate
Stgnalure of f'ker rriving.r-jalfty (or aCtach (`<at;ilily re;cei{aI) _ (tr3tex _- --
t5forn"Adoc- 11112 Systern Pumping Reco rri Page 1 0( 1