HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 340 BRADFORD STREET 12/18/2025 Commonwealth of Massach(,isetts
City/Town cf
System Pumpir�g Record
�y n Form 4
DEP has provided this forrrr for use by Inca! GSowds of HeI filth. ("ether forms may Na usC cl, but the
inforrnation rnust be substantially the sarne as that provided here, Before using this form, check with your
local Board of HezjHh to determine the forrn they use -L he System Purnpirtg Record Must be submitted to
the local Bogard of Health or other approving authority within '14 days from the pumping date in
accordance with 310 CMR 1) 351 w _......_ .._ _
HOUSE front ba sir 7')-ear lefr�,rt 'hi
A. Facility Information 3UILDING� front back side rear left right
important:when
DECK: under
(Illing ot forms ystern Location
on the cornpi;le=r, g /�
use onlytho tab
key Co move your !\ddr o s
Cursor-do nol
use the rc;tum __. .. _ ._.___. .__. ._ ��� . .. . MA
e Y City(1'own ate Zip Code
r System Owner:
f Name
---. .__......__ - _._........ .-_ --._- ..._ -... _..__.._.. _ ._ __.__.. ....._._-..-----------
Address (if different morn ioc;n(ion)
iv A
;IlyfTown State Lip Code
I a 71- .. .:
To�lepV7oner Nur�rkaear
l3. Pumping Record
1 Date of Pumping) 2. Quantity Purnped
DateGallons
3. Cornponent: „ Cesspool(s) Septic farak (__.� (-fight Tank [] Grease Treip
(_J Other (describe):
4, Effluent Tee Filter present? [_) yes if yes, was it cleaned? ❑ Yes
5. Observed condition of cornpone at pur,rlped
.....
6. Syster F'urrlf ed E3y
Dal 'Tin Evtrass '1AA95E Mass 1AD31Z
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Bat.�r�-f-rate.rprises, Inc;
C;crrnpr;rry
7 1 l.t(�In were disposedG t C)
pit rl,aAuw of Date - - -
`lcar7ature, of f,r,t,e;lviny Facility (or alirarh facility rct,r,ifal) Orrtu
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