HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 30 OLD CART WAY 7/20/2026 iown3 Ot North n1 oni-
_ �_ Commonwealth of Massachusetts
v
a City/Town of _ _ JUL 7 2026
- ;system Pumping Record HealthDepartment
-= Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the Sarre as that provided here. Before 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 the pumping date in
accordance with 310 CMR 15.351. _— _-_- ---._-.-----__..__ __._.._ ._.._-.
HOUSE: franc bac ide rear 1 right
A. Facility Information BUILDING: front back side rear left
Important; When
DECK: under
filling out forms 1. System Location:
an the only
the to r, ry �/ 1 �
use only the tab �...o" �^''
key to move your A ress
cursor-do not MA
use the return
key City�f own State Zip Code
-- 2. System Owner:
Name
4& 47TA
reuvn / e)
- -----_
Address(if different from location)
MA
-------
Telephone Number
Number
B. Pumping Record
1. Date of Pumping gate --- —_....______ 2. Quantity Pumped: Gallons__
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): -- ----—— -- — -- ---__—__�_—
4" Effluent Tee Filter present? ❑ Yes ] No If yes, was it cleaned? ❑ Yes ❑ No
5, Observed condition of cornponent pumped;
6. Syst m ped By:
D e 1`iney Mass 1AA95E ass 1AD31Z
_-- __—_ ------.... _ ___--_____ ._----.__.--
N me Vehicle License Numb r
ateson Enterprises, Inc.
y
7. Location where contents were disposed:
GLSD —
-.--__-__--____-.----______-__.____.-___._---.___.-------_-----._._.__
Signature of Hauler Date
Signature of Receiving F acility(or attach facility receipt) Date
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