HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 313 SUMMER STREET 4/13/2026 .� Commonwealtr7 of Massachusetts n ofNorth 460ver
� City/Town of
�} System Pumping Record APR 7 2026°
Form 4
DEP has provided this form for use by local Boards of Health, Other forms may''r Wd1e
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the forrn (hey use. The System Pumping Record rnlist be SUbmitted to
the local Board of Health or other af)provfng authority within 1 1 days from the purnping date in
accordance with 310 CMR 15 351. ----- - -- --- - -- - - --- "..
HOUSE: front 'rack e rear I ri
A. Facility Infornriation SUIlDiNG: front back side rear le I
I [DECK: under
I Important;Whon
filling out forms 1. System.Location
on the computer,
useonly the I a b ------ _- --------- - - -----.—---- -._-. -------...__.._.._
key to move your Address
cursor do not 7w __ � MA
use I h e return ` (� t ...__...- _. _—_____ _..---.-----------
key Clly/Town slate Zip Code
h(/f( 2. System Owner:
Name _----- _.. .. — .__._._._._ ...
, r
ronrn
Address (if diff8rer71 rron-location)
MA
i Y Stale Zip Code
Telephone Number
B. Pumping Record
1, Date of hurnpind - = — - 2. Quantity Pumped ---- ----
Oale Galleons
f
3. Component. ❑ Cesspool(s) jeptic 'rank ❑ Tight Tank ❑ Grease Trap
Other (describe):
_._.___ _.______ __.___--..
I4, Effluent Tee Filter present? (❑ Yes [ No If yes, was it cleaned? ❑ Yes ❑ No
r
I
{ 5. Observed Condition of corn-Iporr12 ( D�{fd:��,„.�
1 &(_rNTZ,_
stein Pumped By e
ve Tilley - - _- Mass 1AA95E Mass 1AD31Z
_. ---- ---- _.- --- — -
i rne Vehicle Ucense Nu er eson Enterprises, Inc
Company
i
j 7. 1 cation where contents were disposed
GLSD
___ __ _ ---
na rE a( Flouter Date ---
Signature, of Recetv{nq Facility {or attach (<,r;ilify (er.eipl) Dale
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