HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 439 WINTER STREET 12/10/2025 A#-, _%1
TOWn
.� Comn,aonvvealth of Massachusetts n ov
er
City/Town ofDEC 15
______
A System Pumping Record
Form 4
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.atprs
DEP has provided this form for use by Vocal Boards of Health, Other forrns may
information rnust be substantially the same as that provided here. Before using this form, chec ith your
local Board of Health to determine the form They use. The Systern Purnping Record must be submitted to
the local Board of tdealth or other approving authority within 14 days from -.he purnping date in
accordance with 310 C M R 15,351 _---
___-- -----.__--_. HOUSE. front 6 side rearc,eftN ,i;ht
A. Facility Inforrtla'tion BUVLDING: front hack .side rear left right
important:When
DECK: under
filling out forms 1. System Location
on the computer,
al S e only the t 0 h .. _4 - �✓ --------------------------
key to move your Andress r
cursor -do not v A
use the relufri _....-_._... .. --- .._-- —.__......_
key. Clly/to 1.wn GCEafe Zara Code
l stem Owr er
14 pad
r ,
lal(✓p '
Address (If different from locallon)
MA
G1ly(1"own
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ___....._..._ ._._--- 2, Quantity Pumped
Date Gallons
3. Cornponent [_] Cesspool(s) """Septic -Tank Tight 'Tank 'rease Trap
Other (describe): --- --.__. _..-
4. Effluent Tee Filter present? Yes (/ � If yes, was it cleanecJ? [] Yes C_� No
J Observed condition of c, n-iponen .)urnped
6 f-;y f ri-r i=D° r-n p e d By
Name
iney Mess 1AfAc15r. Mass 1AD31l
me VF hicle Lice Nu nb
Bai�sol_Enterprlses_.Inc.
.�tm'lpEany
I Loc,a n..wlieI,e curl is were dls c7 u
C� C
Ignature of Hauler Da(e
`ignature of R cclving Facility (or atl ach facility (ecelpl) Date
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