HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 154 ROCKY BROOK ROAD 11/17/2025 Town
*rth
Commonwealth of Massachusetts day r
City/Town ofNOV 2 System t e m Pumping m i n R �ecord
=. Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be us 913t the
information must be substantially the same as that provided here. Before using Phis form, check with your
local Board of Health to detern-tlne the form they use The System Purnping Record rnust be subnmjtted to
the local Board of Health or other approving authority within 14 days from -,he purnping date in
accordance with 310 C M R 15.351, ---------_—.------------__.-----------------------------
s id e
HOUSE: front n e f K
ear r i f,
A. Facility Information SWLDING: front back side rear of ri
important;When
DESK: under
(Illing out forms 1 System l oc atlont
On the cornputer,
use only Oho lab J_ i- ---
key to move your Address
cursor do no( /V fvlA
use; I I i e r e t u f n ---- ---... - ----�-4�C�;�.. - - -.. _... -
key. Clly/town S(a(e Zip Code
2. Sys r Owner:
r -:2
Address (if different (torn location)
MA
CMlyriown Slate Zip Code
Telephone Number
B. Pumping Record
--_._ __. --- l«jG
1. Date of Pumping -- ?... Quantity Pumped. --------___..__..__--
Dale Gallons
3. Cornpooent. ❑ Cesspool(s) �13 eptic Tank ❑ Tight Tank ❑ Grease Trap
L.� Other (describe): _.__ . __..____ ________- _.___.___.._. _ —___-__ _._._-- -
4, Effluent -Tee Filter present? Yes [--I,N'o If yes, was it cleaned? ❑ Yes 0 Pilo
5. Observed condition of cornponent purnped:
6 -1-Pumped By:
__-_-_-- - -- - ---- -—-- ---———- -Mave 1iney Mass 1AA95E ass 1AD31Z
t oe Vehicle License Nu77bet
w
_.-._.-
on _.----
Enterprises, Inr _.. ~
company
7 Location where contents were disposed.
Slgnalure f Hauler Dal ,
Signature of Receiving Facility(or `a((ach facility receipt) Cate ----__.__.—._.-----------.-- — —
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