HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 30 LACY STREET 4/7/2025 Commonwealth of Massachusetts Towr
,
r_ City/Town of
L° System Pumping Record
APR 1 2025
Farm 4
DEP has provided this form for use by local Boards of Health. Other for ° yb ��, but the
information must be substantially the same as that provided here. Before using this ,kc ith 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 CM 15,351. — ---- --- - --
HOUSE: front` back side rear left right
A. Facility Information BUILDING: o"nt back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab `
key to move your Address—
cursor-do not 4 MA
use the return " " � :"
key, City[Town State Zip Code
2. System Owner:
�F�` Name
retrrn f` `'U
Address(if different from location)
MA
City/Town State
Telephone Number
B. Pumping Record
1. Date of Pumping paid 2. Quantity Pumped: Gauons
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:
y {fir'�"`❑.T .�_ __----___.___ __---------
6. System Pumped By: _-....-.,.,.-
Dave Tlney — Mass 1AA95E " Mass 1AD31❑ —
Name Vehicle License tuber
Bateson Enterprises, Inc. —
Company
7. L r�ation where contents were disposed:
GLSD
Signature of Hauler Date --
_---------— ------ -----------
----- -- ---.. ---
Signature of Receiving Facility(or attach facility receipt) Date
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