HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 675 FOREST STREET 12/29/2025 ��
Cori monwealth of Massachusetts o �o �"V
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J N 2 8 2026
"•. / Form 4
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forr i,ationus e substantially the same, a ha( provido-,d helre �e orr ( ck with your
local Board of Health to determine the form they use. The System Purnping Record must be submitted to
the local Board of P--lealth or other ,)pproving �3uthority vvilhin 14 days fror-r7 the purnping mate In
accordance with 310 CMR 15 351
A. Facility Information _--- . . . __ .._..___. ._ ._ BUILDING: front back side rear left right
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key. City/Town Sate Zip Code
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Address (if different (roar Iocalivn)
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C(ty(1 own Sl atn Zi Code
T Irf��hc>rre Numt er _.__
B. Pumping Record
1. Date of Pumping _..._ 2 Quantity Purnped _ _...__ ._ ._...
dale Gallons
3 Component _
( [...] Ces�spac,l(��>>) �,� U`7eptic 1�arrk ❑ Tight Tank 0 Grease Wrap
Other (describe)
4 Effluent Tee Filter present? [f yes No If yes, was it cleaned? E] Yes (-_) No
5. Observed condition of xr))ne � rn)e
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6. Lst. ped ByMuss 1ACj ;Vchlcle tic
B ateson Enterprises Inc
Company
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7. I_(7G tion 1 re S spc
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