HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 101 CROSSBOW LANE 4/16/2026 Town of, � (
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4' Heaa,
Meet
DEP has provided this form for use by local Boards of Health, Other forms may be used,-but the
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information i-nust be substantially they sarne as lh,;t provided here. Before, rasing This form, check with your
Vocal Board of Health to determine tyre form They use. 1 t-re ;System Pumping Record r-nust be submitted (o
the local Board of kle,—,klh or other approving auIhon(y vviihin 14 days from she pumping date in
accordance with 510 C M R 15 351 ----— -- __. ----...
HOUSE: front Q�ac.k 5 ie rear If, r
A, Facility Informatlotl SUILDH\JG: front back side rear left ri
DECK, under
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on the cornpuler, ,( 11 O /
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use IYte reti.rlri key cily/-C*own rr slate Zip Code
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Address (if different from location)
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own stab Zip Code
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r B, Pumping Record
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Date of f�urr7pinrl __._... — - _-__ 2. QuantIty Pumped .s __. .._
f air Gallons
3 Component (_..f CE.sspool(s) epti<, -rank [-� -right Tank ❑ Grease Trap
[� O(her (describe): _.. ___..
4. Effluent Tee filter present? -1 'Yes If yes, was it cleaned? Yes No
5. Obseived condition of con-tponent pumped:
System Flurnpec By:
Dave _tir�ay � Mess '1! ,95E Mass 1AO IZ
_ _ ---- _..__ _.._._
N Vehicle License Nun ber
2 'tson E_n1 erprlses Inc
�rrrPI-a ry
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j - Loc (ion whe, ontents-were dispc)sed
C]L.S(
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igntali.rrr, of Haute( _ L3lu
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V 151orro4i.doc- 11112 Systern Pun ping Record - Page 1 0(1
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