HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 10 DEER MEADOW ROAD 3/10/2025 IuGLU;'ede Ie
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Commonwealth of Massachusetts
ity[Town of
System Pumping Record
S
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Providied here. Before using this forma,tcheck with your
loot Board of Health to determine the form they use. The System Pumping Record must be submitted to
the IocW Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
hnportant:When
is Mount foamy 1. System Location:
rnpuler
use only Ole tab`
key to move your ,
cursor-do not
use the return 1 V
key.
State
State
2. System Owner:
Address(If d rent from
twit/-T wn - _u
State Zip Code
iii
t. Cate of Pumping ---���_
Date � C� �...._, 2. Quantity Pumped:
3. Component. ❑ C s
1(s) Septic Tank [ "bight Tank
Grease Trap
�I Other(describe):
4. Effluent Tee Filter present? ❑ Yes No
❑ if yes, it cleaned"? [ Yes ❑ 1c:
5. Observe d,cOnditiOn of component pumped:
------------------
S. System Pumped!ray: ..
Narne
Vehicle License
Zompany
7, Location where contents were dispo
�..�.._... � .gyp\
of�Haulerin-
Fa Y(or „_ _ chit retaipty _� " rote—�
11/12
Sy$l"M Pumping Record•Page 1 of 1
