HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 55 FULLER ROAD 12/12/2025 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local. Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of E-iealth or other approving authority within 14 days from the pumping date In
accordance with 310 CMR 15.351.
----- __---.—.___---_.____.__. _ _ HOUSE: front ac< iIcle rear Ire right
A. FacilityInformation BUILDING: Front back side rear left right
Important:When NECK: under
filling out forms 1. System Location,
an the er'
use onlyly the Cho tab ,
key to move your Address
cursor-do not
use the, return MA ----------- ._— --- -- _..----y City/Town State Zip Cade
%r 2. Syst m Owner,
1 a m e
Address (if different from location)
MA
Zip
___
Telephone Number
- --
___________.
B. Pumping Record ,
_
1, Date of Pumping Dale � - --- -- 2. Quantity Pumped:
3. Component: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank
Q ❑ Grease Trap
❑ Other (describe): _____—_---__.___.._
4. Effluent Tee Filter present? ❑ Yes L;�'"No If yes, was it cleaned? ❑ Yes ❑ No
6. Observed condition of cor-riponentlpumpe
6. ystem pied By:
ave Tlne Mass 1AA9 Mass 1AD31Z
Arne
r r Vehicle Licens Number
Bateson Enterprises, Inc.
Company
7. Cocaion here c ��� -re disposed:
------------------------------------
Siynature of
Signature of Receiving Facility (or attach facility receipt) Date _
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