HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 31 JAY ROAD 12/19/2025 Commonwealth of Massachusetts
�� wa City/Town of
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Heaith. Other forr-r1s mray be used, but the
nforrnation must be substantially the san-te 7s, that provided here. Before using this form, check with your
local Board of Health to determine the form they use The System Pumping Record rnust be submitted to
the local Board of Health or other approving authority within 14 days farm the purnicing state in
accordance with 310 CMtk 15.351 — _
/�. �Ot1 F _... ff0US(, ront . r:ck side rear IF f ...(I ht
Facility ornlatiofl BUILCalfrl(,]. front back side rear Ie t if ht
Important: Vvheri C)ECK: under
{filing cut forrns 1. SystonT Location.
On fho c arnput€u, ( ��
uS e only t h o t a h \ .. __._...._.__ _._._._. ...._..._.. .. ... . ......_ .......... . ......__.....__._.._ __ ,....._... .___........._.__ .._..... _....__.._
key to rnovrn your Addross y
use cursor r o nnl �� t p� . MA
use the rr;Uurrr __.____.-.._ _ _ ..._ _._..-.... _._.__.....,_.
key. C%Ity�i own Slate Zip Code
2. System Owner: r'
Nnn'"fe
Address (if different from location)
MA
r,Ityro�wr, S t t0
7eIe,piIone, hlurnbe-r
B. Pumping Record
V ._ , I1. Gate of Pur7if�ing __ _ ..___. ?. Quantity ntit Pu �d.
()ar(r p" G flops
3. Component: Cesspool(s) optic Tank Tight Tank
9 ❑ Grease Wrap
[a� Other (describe):
4. Effluent Tee Filter present? [ ] vs (�.� hJo If yes, was it cleaned?
5, Observed condition of cornp,orlent �urrtl:,r�rl
,r
6. (ateson
ste .t Plar7�pecl By:
ve _f Ir)eY_...- Mass 1 AA95t ass 1 AC�31Z
—..
( }'1C;f:', t...l(f fl`vC; NuITI f;",f F r-r�erprises Inc.
C rl{�rtny
7. oca lot) here ontents were dlsf:)C7;ed9
CAL SCJ
1,10 malure of Haule(
Date^. _
lgrrature of F2ec,e,iviny i='acillty (or altaeh facility receipt) C)alc
l5forrn4.doc- 11112 System Purnping Record Paqe 1 of 1