HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 84 CANDLESTICK ROAD 11/19/2025 Commonwealth of Massachusetts
T0Wj7 of City/Town of " j r over
== System S Pumping
== - Y Record
-- :-- ? Form 4 V� v 21 20?5
DEP has provided this form for use by local Boards of Health, Oth may be used, but the
Information must be substantially the same as that provided here eor wtai check with your
local Board of Health to determine the form they use. The System Pumpingr r Rec bmited to
the local Board of Health or other approving authority within 14 days from -.he pumping date in
accordance with 310 C M R 15.351.
HOUSE. con a c k side rear le n5h
A. Facility information BUILDING: ont back side rear heft right
Important:When
[BECK: under
filling out forms 1. S)ystem Location.
on the corrtpuler, (/1 ) rt ,spy
use only the tab - �- t.l _l _ . _'`G'----- - .._ --... ------------- ----
key to move your Address
cursor -do no( f
use the return -- -------.--. - ._ ----- MA
key Clly/7own Stale — —__—. Zip code
2. Sy stern Owner:
(2 Nance -
ream Y
_ ..___...._ ..-.__—___ . .. _ _..._....._ _...._ ....-.._._-__ ............._-,_._.___........-_-_,_._..._.......__._.._.....-_-_.__._..._._.._.-.. ._.__._.- -------
Address (i( different born locauon)� -
MA
cIf / owr7 - _
Y State
Code
-- 57 �,> ' -- ------- --
Telephone Number
B, Pumping Record
1. Date of Pumping -- --- -- ------ 2. Quantity Pumped - -- --
Dale Gallons
3. Component: ❑ cesspool(s) CSeptic Tank ❑ Tight Tank ❑ Grease Trap
(� Other (describe): __ ..____._ _ . . __ ---._-_.______----__.._-_-_.___.-.___--_-.--____._.
4. Effluent Tee Filter present? ❑ Yes C No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
5. S s t e n-t Pik,n,t f.,)e d By
ave nee Mass 1AA95E Mass 1AD31Z
Name Vehicle License Nr fiber
aleson Enterprises, Inc.
ConIpany
7 Loation whe nt wc:r.e disposed
Signature of Mauler Dal --
_ _ ._ -,--------- _- .----..- ---- ---------------
signature of Receiving Facility(or at{ach facility recelpi) Date — - --- -`-`-
t5form4.doc, 11112 Syslern(lumping Record Wage 1 oil