HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 316 RALEIGH TAVERN LANE 5/14/2025 * � Commonwealth of Massachusetts
h City/Town c�T
System Pumping Record
~= 7Form 4
DEP has provided thtis form for use by local 13nard, of I-{Ear:-rlfP��. Other forrT)s may be, osed. b t Me
information must be substantially the sarne a)s ihat f;)mvided here, Beforr; using lhis, form, chock will) your
local Board of Health to determine the form lhey use. b-ho System Purnping Record n"uusl be submitted to
the local Board of Health or other approving authority wilhin 1 1�1 days from the f�7urnping date in
accordance with 310 CMR 15.351 ___.. -
__-- HOUSE front back ldr, reir Ief�t righ
A. Facility Iriformatlon Bult-DiR)f3i front k»Ck side rear left nf;t,t
Important:VVI)on DECK, u o d 0 1
illling out forrns 1. Sy`tern t_r> tlon
online computer, ZGd?/
i.ise only C h a la ..- *!/¢t ✓._.`^"f_ (! "" y,
�c9y Ifn move your lldtafr,y4 /y �i
cursor-do nol MA V
set hl e return "--- _ -__�._._._____..__._�.__.___ _-.._.-__.._-. .,....._........ _..,...__.._ .._.____...— ____ _.—._.
key. yawn Slate �d Zip Code - over-
2. System -wner: MAY -5 20
25
(` Nome ealt 1
J,lu
«run S' '•f�
Addrr;ss (If different from location)
MA
Telephone f� urnber
_.._---------- _. _.--_._--- ._--_----
B. Pumping Record
1. Date of Pumping __ `.-�'�— --_..____-- 2 Quantity Pumped J _.___._ ....
Dal(" Gallons
3, Component: (j Cesspool(s) Septic -rank (� 'Fight Tank( g [] Grsase Trap
r Other (describe)
4. Effluent Tee Filter presr:nl7 (...) Yeas � Igo if yes, was if cle,@nect7 ' es
5, Observed condition of cornponent purnped.
dry
6. System PUmf_>ed By,
Dave TfneS _.._ Mass '1 �A95 ass 1AD312
rlamo Vehlclr License Ni r
9alew Enferprisps, Inc
Company
7, lion wherc contents wore disposc;d:
�I.SD
5igrlalure of Nar.11e( (}a1e
Signature of fkecelvIng f acuity (or at'lach facility feceipl) 0alr; � ---
Worm4.doc- 11112 `system f''rimping f•;ocortf Pof�}r