HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 181 LACY STREET 11/17/2025 C;ommonweaith of Massachusetts ow
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City/Town of
= - m Pumping NOV System u ping Record 225
E = Forrn 4
DEP has provided this form for use by local Boards of Health. Other forms"� Y�� `��s��d,,b I the
Information must be substantially the same as that provided here. Before using this f�or`i^ ,Ick with your
local Board of Health to determine the form they use. The System Purnicing Record rrlust be submitted to
the local Board of Health or other approving authority within 14 days frorn -.he purnping date in
accordance with 310 CMR 15.351 - --_--.__ _- `
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- _.. ------------ - -- _.._-- ---------- HOUSE: front @ck ide rear Ilefrt t',
k d "` ft
A. Facility Information BUILDING: front b �" rig!
Important: When NECK: under
filling out forms 1. Syst l OC�atlon
on the computW,
use only(he tab
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key to move your Addrra s
cursor -do no( �: f� MA
use the retuen — -.-- _ �,1. _ _ -_. -- -_- _—.--- -__--
key Cllyffo-n �- state Zip Code,
2. Sys em Owners„
_--j ✓ N a r n e
r .
roan '
Addrass (if different from loea(lon)
MA
Cfly�rown Scale
Telephone Number
E. P u rn p i n g Record -----___- ___--
1. Date of P u rn p i n g ---------- - - r--1-... - 2. Quantity Pumped. -------.._...--------
Date Gallons
3. Gompone,nt. ❑ Cesspool(s) (_] .eptic Tank ❑ Tight Tank F] Grease Trap
❑ Other (describe): _._.___ --___
4. Effluent Tee Filter present? U Yes 54"r"lo If yes, was it cleaned? ❑ Yes ❑ No
5 Observed condition of component p(.impe :
b. SysteurnI)ect By.
Ual Tlney Mass 1AA95E Mass 1AD31Z
Pia e vehicle
8 fe '0n Entepises, Inc.
C>mpany
7, Location where contents wefe disposed:
_------__-___._----
Signature of Hauler Dale ---
gnature of Rec- iving Facility (or attach facility receipt) Date
- ---`- ---�
15form4,doc 11112 Systern Pumping Record Page 1 of 1