HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 63 BRADFORD STREET 8/21/2026 Own of'"4ndOVer
Commonwealth of Massachusetts
City/Town of SEP 14 2026
System Pumping Record
Form 4 -fealt,
J �7
D e p a r,tfi,,
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. —; 7----- -----
HOUSE: front backside rear nE�k right
A. Facility Information BUILDING: front back side rear left right
Important; When DECK: under
ofIlling out forms 1, System L ocation.
n the computer,
se only the lab
key to move your Address
cursor-do not
use the return
MA
key, cityrrown Zip Code
2. SysteTzzI,Owner:
Xq 5�ie tto
Name
Address (ifdifferent from
MA
CityrTown �t a t e Zip Code
elephone Number
B. Pumping Record
1. Date of Pumping 2, Quantity Pumped,
pateGallons
3. Component: ❑ Cesspool(s) eptic Tank F71 Tight Tank 7 Grease Trap
F-1 Other (describe)'.
4. Effluent Tee Filter present? [] Yes A"No If yes, was it cleaned? 0 Yes Ej No
5, Observed condition of compone t pumped:
6, stem tilmped By:.
_Dave 1'iney Mass 1AA95E ass I AD231Z
n",
Naame. -----------
Vehicle License Numbtr
B BL
atesoteso
n Enterprises, Inc.
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7. L ation where coQte�to
'Lsw, sposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt—) Uate
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