HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 326 FOSTER STREET 7/20/2026 Commonwealth of Massachusetts OWn ® orb An ov
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City/Town of
System Pumping Records 2 7 zozs
,\ Form 4
DEP has provided this form for use by local Boards of Health. 1 " uk the
information must be substantially the same as that provided here. Before usi g thisheck 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 the pumping date in
accordance with 310 CMR 15,351. HOUSE: fro --
aCk Side rear right
A. Facility Information BUILDING: front back side rear e right
Important; When
DECK.: under
filling out forms 1. System Location:
on the computer,
use only the tab
_------_--.-_--
key to rnove your Address - - --
cursor-do not M p
use the return -- ---- ----- - --- -----
Key, cityf-rown State Zip Code
2. System..Owner,
Name
Address(if different from location)
MA _
CitylTown 8t i C
Telephone Number
B. Pumping Record __..� __ ❑❑------- _-_-
1. Date of Pumping sate _ ----.._____._ 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) tic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4, Effluent Tee Filter present? [ Ye Na If yes, was it cleaned? es ❑ Na
5. Observed condition of c poroo�ent put ed:
6. S em limped By:
.3J..= ...,
ave Tined _ — �- _ ---- __.__ Mass 1AA95E Mass 1 AD 1Z
Name Vehicle License Nu ber - ---
on E n to r p r Is e s,
C_ompany _ --
7. Location wher conten s were disposed:
Signature of Hauler---_--- ------- ---___.-__ _Date —` - v ---
-----._....__-_._
Signature of Receiving Facility(or attach facility receipt) Date
--- ---
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