HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 55 WINTERGREEN DRIVE 1/13/2026 Commonwealth of Massash�.,Isetts �
City/Town of
'282a02
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may bau the
information must be substantially the sarne as that provided here. Before using Ihis form, check with your
local Board of Health to determine the form they use. The System Purnping Record must be Submitted to
the local Board of Health or other approving authority wlfhin 1,',f days from the pumping date in
accordance with 310 CMR 15,351
A. Facility Inforr-natiot7 BUILDING: ont back side rear ltfrt right
Important When
DECK: under
(Wing out forrns 1. system Location:
on fhe cornpu. er,
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use only tho tab `r,.-� ' -9 ..__._- `
key to rnove your Address i
cursor-do not MA
use the return
key,
City/Town State - ------ ----- Zip Code,
f -- 2. Sy Am Own r,.
by
- _- -----
Name
- Address (if different frorn location)
MA
C(ty�Town Stater -----
gyp Cade
TelepY'�onNumber
-----------------
..____._..
B. Pumping Record
r ` r
1 Date of Pumping -_.-- _-_-__ _-_- 2. Quantity P u rn p e d
Gale Gallons
3. Component: ❑ Cesspool(s) Z], eptic Tank ❑ Tight Tank g ❑ Grease Trap
(� Other (describe): _.___.__ _.__.__ -------
4. Effluent Tee Filter present? [] Yes [ a If yes, was it cleaned? [_] Yes ❑ No
5. Observed condition of corriponent purnped
l le'
6. System Pumped By j
Dave 71neY_-..__ ----- - -- -- --- - ._ -- Mass 1 AA95E Mas 1 AD317 /
Nar'ne Ve:hIcle License Number
_...Bateson-
Enterprises, Inc_
Co --
rnpany
-~f=-cation whM Cont fits were disposed:
GLSDD� "�
,f
,F
Signature of 1-63 ilor Datr ---_
Signature of Recelvinq'Faallty (or attach facility receipt) DRP? � ---�
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