HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 71 WILLOW RIDGE ROAD 4/14/2025 Commonwealth of Massachusetts
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City/Town ofAPR I 2025
xx ° Systern Pumping Record
F o r rr1 4Hec
DEP has provided this form for use by local Boards of Health, Other forms may be used, but�e
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 Ihey use. The System Purnping Record must be submitted to
the local Board of Health or other approving authority within 14 days from -.he pumping date in
accordance with 310 CMR 15.351, _-_..._
__._. __. HOUSE �... fuck side rear left ig
A. Facility Information _._.-. ¢uI�DINr; rent t back side rear`I"'e rill
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fining out forms 1. S stem Location
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key 'lly/Town stale Zip Code
1�u2. Sy Owner:
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Lip Code
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Telephone Number
I B. Pumping Record
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1, Date of P u rrt y i n_
E 0 a1e ". _ —. 2. Quantity Pumped.
Gallons
3. Cornponent: ❑ Cesspool(s) Septic Tank ❑ Tight Tank g ❑ Grease Trap
I
(� Other (describe):
4, Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
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5. observed condition of component purrlpFsc
5. Systerrl Pumped By.
(Dave 1"innY.__._____ ._ ..___. Mass 1AA95E Mass 1AD31Z
Name .-_— ---- _.----______
r Vehicle License Number
Baleson Enterprises, Inc.
Company
T Loca(ion Where contents Were disposed:
GLSD
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Signature of ti' le( _ alu
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Signature of Ft€;t;eivin(l F,.arilily (or all ecri facilely rc;cr;lf>l) (7atc,
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15(orrn4,doc' 11112 Syslem Pumping Record - Page 1 of 1