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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 180 MILL ROAD 3/25/2025 ` Commonwealth of Massachusetts ' City/Town of 041 M -� - System Pumping Record p � 1�n Far 202 m 4 -s DFP has provided this form for use by local Boards of Health. Other form 10, used, but the information must be substantially the sarne as that provided here. Before usin check with your local Board of Health to detern")ine the form they use. The System Pumping Record t�rlrs submitted to the local Board of Health or other approving authority within 14 days from *.he pumping elate in accordance with 310 CMR 15 351 __. _-__._ ...._... HOUSE. front bark side rea left er, A. Facility information BUILDING: front brick side rear left rigr Irnportank:When DECK: Finder filling out forms 1. Sy,,tern Location on the computer, /// use only the (ab __.___ __.--- --._-. { key to move your Address I cursor-do no( ,�/-'/ 411 MA use the return ty/1"ow - --___ _ -.._._ _._..._..._.__ --- — �._____ __ _ b. key n Stale Zip Code �i Y 2. SySt .n1wr7er: 4115-Z-1 `a�,� fVaf71C �� -......_ ___.. __.._......... _ __-._, _i -._.--_- -....._. .- _.........-. _.,,..._.-.-_ ._.__....-.._.. ..............--_ ----.._...__..__..____-_._..__...._....._..__.._._-_-_.._._..._.----.____ Addr©ss (if defferter�l Irom locallon) MA Zip Code 4 Telephone Number B. Pumping Record 1. Date of Pumping Dale ? Quantity Pumped „ Gallons d f, - 3. Cornponent ( ] Cesspool(s) Se�tl'ank (—] Tight Tank 71 Grease '(rap i Other (describe) _--__ t 4. Effluent Tee Filter resent? p �_� Ye __ No If yes, was it cleaned [:) Yes [] No 5. Observed condition of component pumped: J V � 6. Systern Pumped fay Dave Tiney------- Mass 1AA95E Mass 1AD31Z _.._..._____....______......_.. r Vehicle Llrense CVcarnber Bateson Enterprises, Inr. ___ _.... ------. _. Corripdny 1. L.ocaiion where contents were dispnsed> GLSD - --_- --- Sig ur, Mauler Date Sign Aura; <>f Fy�Ceivinq Facilely (car o7tl 3r,}) (<+r�ilily rr ,cr;ipO Date -_---------------- l5torm4.doc- 11(12 System PL)mping Record - Page 1 of 1