HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 10 LIBERTY STREET 3/18/2025 NorthTown of
= � Commonwealth of Mass-achusetts 4$$�/y[d/�/�4p
City/Town of
Pumping n�
Sy
stem� Y p g Record ,
\t _ Form 4 Healb"
Xrt
DEP has provided this form for use by local Boards of Health. ether forms may be used, but the
information must be substantially the same as that providers here. Before using this form, check with your
local Board of Health to determine the form 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 IS 351 ____- ____.
I:t?USE : front back 5irie rea r Crght
A. Facility information BUILDING: front back side rear left rir,ht
Important: When
DECK: under
filling out forms '1. System Location:
on the computer, ��/ -
use only the tab L . P�
key to move your Address
cursor -do nor use the return � MA � '���'
key, City(iown Slabs lip Code
/ 2. System Owner:
Address (if different from location)
MA
City/Town Shale lip Code
-T—e -h--ne -N-ur-n-b--er--------------
B. PLarnping Record ---------------------
1. Date of Pumping ---____ ___..._..____...____-_-.- Q u�a n t i t y Pumped: —_
Dale Ca;7 ilonS
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4, Effluent Tee Filter present? ❑ Yes ( Na If yes, was it cleaned? ❑ Yes [ J No
5. Observed condition of cornponent puirtped:
S. System Ptamped By:
Mass 1AA9SE --,- Mass 1A031'7
Name VehIcIP Ucenrc N irnber
Bateson Enterprises, Inc. �— —
Company
7. c, On where contents were disposed:
GLSDY
Sign ture I-iauler Cate
Signature of Rccelving Facility (or altach facility receipt) Date --- - --
t5form4.doc- 11112 Systern Pumping Record Page 1 of 1