HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 260 BRADFORD STREET 5/28/2026 Commonwealth of Ma own of No ndovor
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City/Town of MAY
Y 2 9 2026
=' ° System Pumping Record
Form 4
Health Depart ��
DEP has provided this fom-) for use by local Boards of Health: Other forms may be used, but th
nforn�atlon must be substantially the sarne as that provided hera. Rpfore using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from -he pumping date in
accordance with 310 OMR 15 `i1 __"
HOUSE. front (back Aside rear Ift� right
A. Facility fntorniatlon BUILDING: front back side rear left right
mportant;Wf7ern DECK: Under"
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B, Pumping Record r,
1. Date of Pumping u _.. ....---- 2, Quantity Pumped.
Gal o n s_._ _._ _.-__
3. Component: ❑ Cesspool(s) [ septic Tank ❑ Tight Tank
F] Other (describe): _-_ _.
4. Crflt.rent Tee Filter present? [_� Yes (_. o If yes, was it Cleaned? [] Yes ❑ No
5. Observed condition of com pon - ar-n ped
6. (avy
lr) P�:1" 'tped By
( TtneY__ _-- r License Anse r n be 5 Mass 1 AD31�.,
ve
Bafeson Enterprises, Inc _. _..
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Company
7, l_oQation where contents were disposed
Signature of Hauler Dal
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Signaturc of Receiving f acdity (or attach f,7icilily rr.rript) Dates - --
15form4.doc' 11112 System(lumping Record Page t of 1