HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 483 JOHNSON STREET 4/29/2026 Commonwealth of Massachusetts a r f r�
� ov G 7A City/Town of
System Pumping Record MAY 1,3 2026
Form 4
DEP has provided this form for use by local Boards of Health. Othftlk paftqnt
information must be substantivally the sarne as that provided here, Before using This form, check with your
local Board of Health to del:ermirae the form they use The System Pumping Record must be Fubmitted to
the local Board of Health of other approving authority within 1/1 days from the humping date in
accordance with 310 C N1 R 15.35'1 _-.- __ -___.. ___.___--
HOUSE: front (!:�c9 side rear left-
A. Facility information BUILDING: front back side rear left riplo
Important: When dP..I'
filling out form> I Systerin L.oc;�j7tion
ors (lir: computer, .. ✓ � ��� +e r>nly IYis lab
key to rr)ove;ycaur Addross p
arse r-der no( ,r /lsf" MA
the retum
key. city/Town ^late Zip Code
2. Systenn Owner,
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Y_i of(��° .._ _ ( i
N.r rr'i e
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Address (if different
I(oRl OGal�lofY)
MA
City/T own S!<'ele
Zia code
rr le lane n er
B, Pumping Record
1, Date of Pumping V
p J Isle._ 2. Quantity Pumped
gallons
3 Component: [_] Cesepool(s) (_ ��tic J'<:ank
�_._� right Tank Grease Trap
j C7tf-ler (describe) -- ____
4. Effluent Tee Filter present? (_-J Yes (.._ No If yes, was it cleaned? �_..I Yes [_J No
5. Observed condition of cornponent purnhe(,i
6. Sy0' "�
ed By
Qa1Af>95 Mass '1AC�311
�shilGe l it cn�,r, NurnbcBa rises Inc
CarnE7any _.
7. L-oation W(Ier cor'ItentS were disposed
;3ignalurn of Pkr r,eivinc� fr3cillty (ui alirar'.h (flCilily rrr,u�pl) 17,rtr, _._. _._
�(r�rn74.doc 11111 System Pumping Record %qe 1 crl 1