HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 178 BRIDGES LANE 4/9/2026 t Commonwealth of Massachusetts over
City/Town of
APR_
System Pumping Record 2026
Form 4
[CEP has provided this form for use by local Boards of Health Other,forms may he us e,
information must be substantially the same as that provided here, Before, using this form, check with ycai_ir
local Board of Health to determine the fora} they use. The systom Pumping Record must be submitted try
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15 351 .._............
HOUSE: front �ac�i�cl� rear Ieft iPht
A. Facility infornlcatlorl E,()It_DING', front: knack sicle neat Ieft right
Important: When DECK: ur1der
.fillip out forrns 1. System OC n:
or) m c(he couter,
use only the tab
_._..:.__.. ............: 6..�-„rµ
key to move your
rses r-do rot 4ddrrss _.._ _ �L MA__ — —. . _....... _...._...
Key y(iown Sfafe Zip Coda
f 2. S St rrl Owner:
-
_ —
Name
Address (If different from location)
MA
cltyrrowra Slate _ r�p c�ode
elephone Number
B. Pumping Record
'1. Date of Pumping 0ilr _._.._-_- 2. Quantity Purnpc;d
Gallons
3. Component: ] Cesspools) G, eptic 'Tank [ j Tight Tank Grease 'Trap
❑ Other (describe)
4. Effluent Tee Filter present? D Yes Nr, If yes, was it cleaned? D "yes 0 No
S. Observed condition of corn)orient p r rp a
6 sten't Pumped By:
ave TineY__ AJ.___ .-_.___.____......_..__ Mass '1/ Mass 1 AD312_
-_._ _._._ _. .. _._
aine Vehicle t_irense irnber
Bates. enterprises, Inc.
any �
7, ocatio wt ere oaten osefj.
Siynaiuro of t-Iaulor Dato
Signature of rkeceMny Facility (or atlacPi facility receipt) Date.
t.5forrn4.doc- 11112 Systelrn Purnping Record • Pac)e 1 of 1