HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 742 WINTER STREET 11/14/2025 tl
rCommonweith of Massa'chusetts
ZOECity/Town of
System Pumping Record
C Form 4 r 4: Health
e
DEP has provided this form for use by local Boards of Health. Other farms may be use PPq%Qnt
information must be substantially the same as that provided here. Before using this form, check with your
Vocal 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 ump�g date in
accordance with 310 CMP 15.351 ___________.
HOUSE: f r o n t b side rear I e ,r i f h t
A. Facility Information BUILDING: r°ont back side rear left right
Important: When DECK: Linder
filling out forms 1. Systern Location,
on the computer,use Y
key only the your Acid S 4W4- _ _...._.__.
cursor-do not
use the return _ __...._.
-- ---- - -
keY ityf rowrr Slate Zip Code
2. System Owner:
fly+ r
--] 1/1
Na rn e
l\\
renrn�l(7
Address(if different from location)
MA
Cityrrown State
_ lip Code
..........
elephone lurnber
B. Pumping Record
1, Date of Pumping -C7at<; __1�._,._�_� ._.--_.-- ?_. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) �1 .�eptic Tank ❑ Tight Tank
��"'", � ❑ Grease Trap
❑ Other (describe): _._____.- -_--_______--_.___.__.
4, Effluent Tee Filter present? ❑ Yes �a If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped: /
0. S rr1 Pumped By
ave Tlney Mass 1AA95E M_ ags 1AD31Z
ame � _.._.__ Vehicle License Nunn er
Ba can Enterprises, inc.
Company __..
7. Location where contents,verE disposed
LSD
Signature of Hauler D S
te .....__------
i nature of ReceTving Faciity or attach receipt)
Date
t5form4.doc- 11f12 Systern Pumping Record -Page 'I of 1