HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 41 CROSSBOW LANE 7/17/2026 Commonwealth of Massachusetts TO Wn o r North 4 n
ever
City/Town
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° System Pumping Record z�z6
--," Form 4
o,91th
DEP has provided this form for use by local Boards of Health. Other forms may be used, OMPVent
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: front k side rea le right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
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use the return City/Town --- State— Zip Code
key.
nl ,�y 2. System Owner:
Address(if different from location)
_ MA
--State i Code
Cit fTawn -- _—
Telephone(Number
B. Pumping Record
..-_
1. Date of Pumping (Date �—_--- 2. Quantity Pumped; Ga11ons
3. Component: (❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. stem Pumped By: °
Dave Tine Mass 1AA95E 1llass 1AD31Z -
Name Vehicle License Num er
"-Bateson Enterprises, Inc.CDompany
7ion water contents were disposed:
Signature-of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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