HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 210 CANDLESTICK ROAD 11/14/2025 (e"\ Commonwealth of Massachusetts jn OV
er
c h Ma City/Town of
_ - System Pumping Record NOV 14 202
F =f Form 4
DEP has provided this farm for use by local Boards of Health. Other for rr e
information must be substantially the same as that provided here. Before ulipsing this form, k 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 CMR 15.351.
HOUSE: 1i rout back sills rear left right:
A. Facility information BUILDING: front back side rear left rig; rt
important;When DECK: under
filling out forms 1. System Location:
on the computer, ?
use only the tab
_...
curto move your Address �u
cursor-do not /�`4�f 0/`) ,I MA
use the return —____ . ._._ _-.�_.. __._..
cit crown __.-- --___.__ __.". .._._._ .r __-----_—__--
key, .:,,rate zip code
Qv/ r' —� 2. System Owner:
1
Name
reran � t
------------
Address(if different from location)
_____ ._ ..._____.. __.._.... _._ __.._...._ MA
CikyJTown State Lip ode
telep one Number
B. Pumping Record
1. Date of Pumping Datr _ ..-._ .___.___._--- 2, Quantity Pumped:
Gallons
1 Component: ❑ Cesspool(s) '`Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe),
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? [] Yes ❑ No
5. Observed condition of component pumped,
6. Sy tem`"Pumped By:
Da Tine Mass 1AA95E Mass 1AD31
Name Vehicle license Number
Bateson Enterprises, Inc.
Company
T Lcic,ation where cQlaLents were disposed:
G f'
Signature of I-iauler Date
Signature of Receiving Facility(or attach facility rF,ceipt} Cate
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