HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 54 VEST WAY 4/18/2025 Commonwealth of Massach(isetts OWn Of'Vo'th 411d0ver
City/Town of
System Pumping Record APR 28 2025
Farm 4
DEP has provided this form for use by local Boards of Health. Other forms ma
information must be substantially the same as that provided here. Before using this fo"rn�, cftwith 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 R 15,351
HOUSE: front back ide re right
A. Facility Information BUILDING: front back side rear le right
Important: When DECK: uncei
filling out forms, 1. System Location
on the computer,
use only the tab
key to move youf Address
cursor-do not JAT
use the return
key. Zjtyffown State Zip Code
2. System ner,
t��f
Address(If different from location)
MA
—----------
Clty/Town state(," �_ Zip Cod,
`Telephone--Number
B. Pumping Record
1. Date of Pumping 2, Quantity Pumped.
Date -Gallons
3, Component: ❑ Cesspool(s) Septic Tank ❑ 'Tight Tank ❑ Grease Trap
Ej Other (describe): ......
4, Effluent Tee Filter present? 0 Yes ) No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition f component pumped.
6, System PQrnped By,
2ave Tlaey Mass 1AA95E Mass�1AP311
Name Vehlcle License NurQr�
eMeson Enferprises, Inc,
Company
7. 'on where contents were disposed:
-Signature o I e f ...... -Date
FacilitySignature of Receiving (or attach facility receipt) Dale
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