HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 416 RALEIGH TAVERN LANE 4/17/2025 Commonwealth of Massachusetts own of r
City/Town of
APR 1
System pumping Record 202 r
- Forrn A
DE"rP has, provided this form for use by Iocal Rw.'lyds of Health. Other forrns
information must be substantially the same as that provided here. Before t-�)sing this form, L11.ck with your
local Board of Health to determine the forn'1 they use. The System Pumping Record must be submitted Io
the local Board of Health or other approving authority within '14 days from the purnping date in
accordance with 310 CMR 1.5.351
HOUSE front o k�.side, rear lei right
A. Facility information BUILDING: front beck side rear IPfr nght
Important; Wien
DECK: unc':ier
(Ildlreg out forms 1. Syst rn location,
on(the computer, r f, Ile
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use only the tab r _-
key to move your Address
cursor•do not MA
usethe return — ►—"—_-__ ._.___._. __....___ __. ___.__�_.____- __-.____ --------- -.__.
key GCy lawn ,tE�try !ip Code,
,_. 2. Systern Owner:
N 2 nY 0
Address (If dofterrsni frorrr IocaUon)
MA
ClfyfTown Clal«: Zir>Code
y !"' � tca
Telephone Nurnt7er
B. Pumping Record
1. Date of Pumping ___...__....._._....-_---.._._._._._____. 2. C,tuantity Pijrnp Gallons
vale allons
3, Component: ❑ Cesspool(s) Septic `Bank ( j Tight Tank ❑ Grease Trap
Other (describe): _. ._ .___._ __..._.___-- _.._.._ ._.. .._.__ _......
4. Effluent Tee Filter present?0
Ye _] No If yes, was it cleaned? Yes ❑ No
. Observed condition of c(rnponent pumped
6. System Ptimped By:
Dave Tlne Mass 1AA95F Mass '1AD31Z
Name; Vehlcoe License Nurn
ea�eson Enterprises, Inc_
Cgrnpany
7. Ort whirr contentswere disposed.
Signature of Hauler Oate
Signature of Recelving Facility(or attach facility receipt) Cate
t5form4.doc, 11112 System Purnping Record f7acle 1 of 1