HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 981 JOHNSON STREET 12/10/2025 Commonwealth of Massachusetts rO W17 of lVorth A 17do
City/Town of Ver
System Pumping Record Ze 1 ,5 2025
Form 4
DEP has provided this form for use by local Boards of Health. Other forms mwg; tj�4 the
.18, 1
information must be substantially the same as that provided here. Before using this for MWour
local Board of Health to determine the form they use. The System Pumping Record must be sub 1 d to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CM R 15.351
HOUSE: f(o!�_)back side rear left
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, I
use only the tab �Y&)�('O �em
key to move your Address
cursor-do not A) c MA
use the return
key. CityfTown State Zip Code
2. System Owner:
�&-
Address(if different from location)
MA
Cityfrown State Zi C
6o—� 0 qL 9Qc-�P)
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: M Cesspool(s) [-'Septic Tank F-1 Tight Tank M Grease Trap
F] Other(describe):
4. Effluent Tee Filter present? ❑ Yes 2-No If yes, was it cleaned? F Yes R No
5. Observed condi io of component pumped:
;00(P
6. ste Pumped By:
ave Tin
e... Mass 1AA�5E Mass 1AD31Z
'a
ame Vehicle Licens Number
r ris
L es, Inc,
ateson e2��—. -
C c
o
7. C,atio7;
here�cAontents were disposed:
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Signature of Hauler Date
Signature�of Receiving (®rat attach facility i�ceip—t) --- Date
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