HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 57 CANDLESTICK ROAD 8/4/2026 Commonwealth of Massachusetts
1, City/Town of
Y System Pumping Record
/1 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 sarTte as that provided Mere. 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 C M R 15,351, .-
__ HOUSE: ant "back side rear ght
___----..-_._._.__._________..._
A. Facility information BUILDING: front back side rear left: right
Important:When DECK: under
filling out forms 1. System Location:
on the corn )uter,
use only the tab —_..---
key to move your Address
cursor-do riot
use the return
Y __._—�.______-. ___ _V_ MA
key. CityFrown State Zip Code - -
(171
— 2. System Owner: "
!! of .V l�❑� t
Nnrr72
--— — __
(jretira � v
Address (iF diFferent from location)
MA
Slat p
I.— Code-------_____.__
Cit /Yawn
Telephone Number
B. Pumping Record
1. Date of Pumping _ _---_ --_..-- 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) [c❑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 componentpumped:
6. S &m Pumped By:
ve T Ir ey.. Mass 1AA95E M ss 1AD31Z
Na, e Vehicle; License Number
Bateson Enterprises, Inc.
--_-.—------------
_..___.
Company
7. Location where contents were disposed:
L D ...
Signature of Hauler Date
- — _.._....._-._._.._.-._.
Signature of Receiving'Facility(or attach facility receipt) Date
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