HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 357 REA STREET 1/2/2025 Commonwealth of Massachusetts 17(1
[`'fy/T{}yy� [}f ^�� ., ~��
~ ~��
System Pumping Record
� ��
F0[D1 4
DEP has provided this form for use by local Boards of Haolth. Other forms may be ua' ~~^--
information must be substantially the same as that provided here. Before using this hz . check-- '� your
local Board of Health to determine the form they use. The 8yohern Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days fronn the pumping dote in
accordance with 31OCK8R 15,351 HOUSE: front back(:s]:d:j�rear(:13e right
A. Facility |nTor0OaI|C]n BUILDING: front back side rear left right
Important:When DECK: under
(Illing out forms 1 System Locetion�
on(he,on num ,
use only the tab
key to move p,v, xuureoy - �� �� —
------
nurso,'uo not
vaethon�*,n MA
Key. City[Town state Zip Code
1 01/E-11 2� System Owner:
MA
Clty/Town 52 Zip Code
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Gallons
3. Component: Caoapoo|(o) Septic Tank E Tight Tank [71 Grease Trap
0 Other (describe):
4. Effluent Tee Filter pnsoen(7 [] Yea No If yes, was it cleaned? El Yea [] No
5, Observed condition of component pumped,
8, System PVrnped By,
Name Vehicle License Nu<ber
Ouve T{nMass I AA95E LMas�s IAD31Z
9a�son Ente I
Company
7. 1 n where contents were disposed:
GILSD
t5fnm4doc- 11A2 System Pumping Record ' Pego 1 of 1