HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 103 BRADFORD STREET 7/17/2026 row
Commonwealth of Massachusetts r of NOW) Ord
over
.�.., r City/Town of `� L 026
System Pumping Record
Form 4 Hea1th
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same 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: frond Ide rear leQr1ga
A. Facility Information BUILDING: frontZi side rear le
Important:When DECK: under
filling out forms 1. System Location:
on the computer, f , -3 j
use only the tab Ar
key to move your Address— _
cursor-do not MA_
use the return key. City/town ry State Zip Code
2. S tem Owner:
Name --
Address(if different from location)
MA
City(Town State ip Code
Telephone Number
B. Pumping Record
_____._ rc
1. Date of Pumping Date �-�� - 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 component pu ped:
M
6?Name
st ". gmped By:
ve Tine Mass 1AA95E Mass 1AD31Z
.. Mass___._..__
Vehicle License Num r
teson Enterprises, Inc.ornpany
7. Location where contents were disposed:
GLSD
_Date
-__ _.__ _...__....__..______�_.___.___...______.__....._..___._-_-__.._._________.____.
Signature of Receiving_— Facility(or attach facility receipt) Da
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