HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 72 SAW MILL ROAD 4/24/2025 To Wn of'Orth
Commonwealth of Massach(,asetts
ndaver
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City/Town/Town of �' 2�
_. Y 2025
.,' Systern Pumping Record
Farrrt 4 � Depart
ment
DJ' has provided this form for t.rsrs by Ioctll of f�salth Other forms may tare used, t>ul the
information n-u.jst be substantially thew s;,arne es; lhot q:(ovidod here. Peforrr using lhi^ fora-•, check, with you.
local Board of HE9,21th to determine the form they tssse Tl�le system Purnpiog Record n-nust be submitted trr
the local Board of Health or other approving authority wilhln 14 days from the purnping date in
accordance with 310 CMR 15,351 -.-- - ......
.--________._.— _— .___ Side d e r e a rCI P 9- r i
h t f-iC7USC rout �aa� side rear CEP
A. Facility Information fUILDING front hack eft rif,ht
Important: When DECK: unCler
Mling ou(forms 1. Systern L._oc;ation
Or)HIE?Cornputwr, � u f
use anly the lab __._� �.�"�"�-'�y Ill
key to rnove your Address �
cursor•do nor �+ pp
use the return ! -( C ( P✓lA
Cit frown
------
key, Y Starr> lip Code
2. Systern Owner:
stti� r� � 'M
----
rrnrn �.'
Address (If different front lacalian)
MA
CIt /Town --
Y Slale ipCodr ----
elephar'ie Number
_,.._._._---_._..-._.__—
B. Pumping Record ;
1. Date of Pumping _..__ -`� --_-.__-- 2 Quantll Pura ed 1
Clare / p
Gallons
3, Component: F3 Cesspool(s) ( _ .Septic -rank (�j Tight Tank ❑ Grease Trap
i ---) Other (describe): ..........
4. Effluent Tee Filter present? ( ] Ye .._,_] 1•Jo If yes, was it cle, ned? �..) Yes [] rVo
5. Observed cond'tion of component purnped:
5. Systern Pumped By,
Dave They _ -- -- Mass IAA95E Mass 1AD31Z
tJar7�r Vehlcle licenses Number -
GMew Enferprises, Inc.
Company
7. L..cation where contents were disposed
(BLS
5igrrr)ture of Nrft.rler 17ale
Slcnalure c>f—Reculvin P`aci11t or attach facility receipt) Oate
15form4,doc, 11112 Syafern f'urnpmg f ecord pack; 1 0l 1