HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 73 FARNUM STREET 6/23/2026 Cornmonwealth of MassRchusetts
City/Town of
SOZ 9_ Iff
m Prm inc Re
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Form 4
JeAOPUV WON 10 UM01
Der' has provided this form for use by local Beards of I-ieaith. Other forn')s may be used, oul thc�
information must be substantially the same as that provided here. Before using this farm, check will) your
local Board of Health to determine the form they use. The System Pun-ping Record must be SUbrnitted tr7
the local Board of I-lealth or other approving authority willrin 111 days, from the pumping r'3ate if)
accordance with 310 C'MR 1
HOUSE front hat:lk side rnnr ( eft rif'ht
A. Facility information RUII_L71NG frr7nt t»ck side rear lefr 6t71rt
Important:VVI)en DECK: i_rnder
(llling out forms 1. Systems Lc)cati on',
e�rt Utc? Corn rittf;r,
use only t1no tat) /1
key to move;your Address
fur> -do not use the
c Mfg
C t f(rrwn _ip....
ke.y. y tale Z C,adr!
2. Syste t Owner:
Name
�6_11111-
211 ]
Address (If differenl (rorn location)
MA
,.w...__ _ _ . _,_...._---....._.._.__ ___...
Y `dale Zif>Godr,___..
Tciophone Nurnber
_._._---------.___.___. _.._.._ __..........
B. Pumping Record
�
1. Date of F7cln7ping 5�llr, _._..._- .-----..-- 2. C raanti(y urrnpr,:ci. Can�rs
1 Component: -f (�..� Cesspool(s) -- Septic Tank. Tight Tank C;res+s(,-, Trap
Other (describe),
/1, Effluent Tee Filter present? Yes No if yes, was it cleaned? [ j Yes
5. Observed condition of con-iponent purnped:
u�r
5. System Pwnped By:
in ey M a s s 10A9 5 E kass 1 A D 3 _
tvame Vrhir.fe (_ican;o P^Jt,rY7t7<:
Bateson Enterprises, Inc
Carnpt>ny
7. �O?n where contents were disproof-C'i:
atiq
uler Date —
Signalurr; of ReceivingFacility (or ra ltach far iIfly rec,(ipO rajf
I5forrn4.doc- 11/12 r>Ystefn Purnininr,) Rr+ctud Pac(rr 1 of'i