HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 270 SOUTH BRADFORD STREET 4/24/2026 Town of North
Commonwealth of M���shch�_ setts over
4 City/Town own of
API 0 202
System Pumping Re(-,ord
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Form 4
'4 'b"Ith Department
DEF' has provided this form for lase by local Boards of Heaith. Other form may be used, but the
information must be substantially ti)e sarne as that provided here. Before using this form, check will) your
lacai Board of Health to determine the form they use, The Systom Pumping Record must be subrnitled to
the local Board of Health or ottler approving 8uthority within 16 days from the pumping date In
accordance with 310 CMR 15,351 __._--__ _.__ ___.-.-
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A. Facility Information dult_DIfNG� side iear Ic(t
Important,when 1 1DFC:K: Linder
(llflrig out fom)s 1 nI o(_"�3t,k'#M�
on the cornpuler, -
s
use only the lab ✓ ` '
keyto move our Addre9s ___ _._..._
Y s _.
cursor do nol MA
u;e the realum _ .__ _-- _-- __ .
Key, City 'own Zip
Code - -
2. ysteni Owne
Addrr3ss (if clifierenl (turn Iocaiion}
MA
City(Town Slate Zip code
Telephone Number
B. Pumping Record
1, Date of Pumping C)a i c--_ _-- -__----__ 2 Quantity Pumped --------------------------
C7allons
3, COMponent: CesP>pool(s) ptic lank Ti- I)f Tan
� �_.� Cr8 a5E•; Tfap
M C th e r _-.__--
f;
4, Effluent Tee Filter present? �'es ❑ a If yes, was it cleanest? [_] Yes ❑ No
5. Observed condition of con�rpone r p4 rlpr?d
- _ -�' 1 _
6, ped By
Da e TIn _..__ Mass 1AA95( LIAD317
—.. ---—Ndr P Vehicle LiC(:n,;g tlrmhE;
Ba eson VNerprlses Inc.
..........
7. Location ere cU its were df�h�"�,
w
-----
Slg�na-tcirc� a( 4-1aul
Signaiurc, of Rcceiv{ng Facility (or attach (acihty ror;oip(} Gt�+lv ----
l5forrn7 doc. 11(12 System Pumping Record p<+tae 1 of r