HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 29 GRANVILLE LANE 1/30/2026 Commonwealth of Massachusetts
City/Town of
stern S Pumping
Y 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 forrr) they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date In
accordance with 310 CMR 15.351 ---_ _ __.__ _ ____
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A+. —inQrr7latiCJf1 BUILDING: back side rea('I 65
t ptit
Facility back side rear fe -t right
Important: When DECK: under
on the corn uter, e ✓ on:
use t tn1
e only tab -y � oCti�i _ 4 ----- -------
key to move your Ad res_
cursor-do not MA
use the return
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ke Cityffown State Zip Code
01, 2, Syste 1 wner:
r a
a
Or
a -- -------_ -- --- — — — ------ - — --- --
Name - --.._...
Z/ 0
Address (if different from location)
MA
City(fown Stale _i Code
f} _-._ ... -...._ . ....
Telephone Number
B. Pumping Record
Gallon
1. Date of Pumping D a t � _---_._----._... 2_. C u a n t t y F'u m p e d: -- ----__.-..---.-----_-._--
3, Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
g Grease Trap
❑ Other (describe)
,a
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? Yes [iJ No
5, observed condition of cor ponent purnped:
6. System Pumped By: --
Dave 71nev— _--- - Mass 1 AR95 Mass 1 AD317_
ame Vehicle l_irense N irnber
Bateson Enterprises, Inc _---..-
Company
7. Localion where contents were disposed:
41u
auler Date
— --------------------- -
-.._.... _. -
gnat.
of Receiving Facility (or attach facility receipt) Date
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