HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 60 SUNSET ROCK ROAD 2/3/2025 Commonwealth of Massachusetts
c=Tw City/Town of
-- °' System Pumping Record
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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: front back side rea qlll�pe-'flt
rightA. Facility Information BUILDING: front back side rearight
Important;When DECK: under
fllling out forms 1. System Location:
an the computer,
use only the tab
key to move your Ad ress
cursor-do not MA
use the return ---.--_____.
key City/Town State Zip Code
s0Q2, System Owner:
__..._........
Name
rerun ��
Address(If different from location)
MA
Clty/Town State lip Code
Telephone Number
B. Pumping Record _
1. Date of Pumping ----- —_� 2. Quantity Pumped; —— ---__e Gallons
3, Component: ❑ Cesspool(s) Septic 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 pumped;
-------- ____-.___.__.__
6. System Ptimped By:
Dave T I n Mass 1 AA 9.5E Mass 1 A D 31 Z
Name Ve umber
eateson Enterprises, Inc,
Company
7. c tion where contents were disposed:
GLS
Signature af` outer Date
Signature of Receiving Facility(or attach facility receipt}
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