HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 706 FOSTER STREET 4/15/2026 own of North�-Ildjo
Commonwealth of M@SS2ChUselts ✓fir
tt�J
City/Town of
APR 17 2626
= System Pumping Record
Form 4
Health DI'Partn
DEP has provided this fornn for use by local Boards of Health. Other forms may be used, but 1 e nt
information must be substantially the same as that provided here. Before using this form, check will) your
local Board of Health to deterrr)ine the form they use. The System Pumping Record must be submitted 10
the local Board of Health or other approving authority within 14 days from the pumping date In
accordance with 310 CMR 15 351. —.--_
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A. Facility Information BUILDING: front back side rear left rif;hr—°°�
Important; When DECK: under
truing our forms 1. System location'
on the only
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use he return r i..- 4.. MA
key. Y rate Zip Code
f� 2. Sy St m caner:
Name - - ----
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Address (if different frorn location)
MA
CityChown ;I:ale I-ip CocJr.
Tele hone Nun?�!e
Fes. Pumping Record
-- . -
1. Date of Pumping DarEr _._.___ 2. quantity Pumped: Canons
3. nt:Com one p [� Cesspool(s) C ,optic "Tan}< n Tight Tank [] Grease Trap
❑ Other (describe)
4. Effluent Tee Filter present? [] Yes [ o If yes, was it cleaned? ❑ Yes [-J No
6. Observed condition of cornpon nt pumped
6.Cav
n Pumped By:
Iney Ma s 1Al9BB Mass 1AD317_Vehicle l-icense Nur7 bt.r
Bateson Enterprises, Inc.
Company
7 Location whet ton ents we s posed:
w
GLSD
Signature of Hauler Date
— - . . ---- — _. ---- ---
Sign alure of Recelving Facility(or agach facility rr�coipl) Cale
l5form4.doc• 1'1112 Systenn Purnping Rncorci