HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 66 VEST WAY 12/16/2025 Commonwealth of Massach(.isetts
t ra City/Town of
System Pumping Record
- - Forrn 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 sar-ne 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 sLlbmitted to
the local Board of Health or other approving authority within 14 days from the pumping date In
accordance with 310 CMR 15.351 --------
HOUSE: fro
= ❑ nx back silo rear le h right
A. Facility Information BUILDING. front back side rear left rif;7t
Important: When DECK: under
filling out forms 1. 5� totLocail
on fhe cornpuler, \``✓'�
use only the tab
key to rnove your Addross
cursor-do not �'° MA
use the return __.___ ._—___._. _ -
_._ - -- -. - -. -------- --—---
kr,y. CityTi�owr7 Sf,ate Z_ip Code - -_
2. S stem Own
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-- _
Address (if different from location)
MA
----------.._ ------- __.. ---- ---- -- — --
City/Town State Gip Code
73
Tcle`- lone Number
B. Pumping Record
1, Date of Pumping Oatc� -- ._ .._._. 2. Quantity Pumped:
3. Component: ❑ Cesspool(s) L�eptic Tank ❑ Tight Tank ❑ Grease Trap
CI Other (describe) ___ __.._
4, Effluent Tee filter present? ❑ Yes /Na If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of corrlponent pumped:
6. stern pumped By
ave TInY-.__---- Mass '1 AA95E M ss 1 AD31Z
ame _
� Vehicle License Nur'nt3er
son Enterprises, Inc,
Company
LSD tents were; disposed:
caUara,wh c, con
i9nalure Of tiraulnr Cate
_._ --- --
Signa(ure o decewing -acility or altar,h facility receipt)
t5forrn4.doc- 11112 System Primping Record Pale 'I of r