HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 268 REA STREET 5/22/2025 Town of NOrth
Commonwealth of v°r
�� • Massach�.asE=�tts
i y1Town of _ MAY 3 0 2025
yste -n Pumping Record
�L Fora, 4 Healthy Department
i DEP has provided this form for r.lse; by local Roards of i�lrrtltYi. Other fo(ir)s rmay be used, bfitlY�r�
information must be substantially the sarne as Ihal (brovided hero. Retforo using this forrn, check wilt) your
local Board of Health Co determine the to(n) they use. The System Pun-tiling Record Must be SW)Mifled to
the local Board of Health or other approving aulhon(y within 14 days from the pumping date In
accordance with 310 CMR 15,351
I
—. ------v---- -_ -- -- — _ If0USC fron(bac side rear let f IT
A. Facility Information — 8UII-DING from hack side alai left rlknl
Important:whop r-)('K u1)Cae"r
(Illing out forms SyStern Location
an the computer, �^
u.se only the lit) 2�
«>y to tryout:your Address
cursor -do not MA
use the retu n --- .- --- ------_-- ---- --
--—---- - - ---- --- --- --.
key, .,ilyrl't>wn Slate Zip Code
2. Syslern Owner:
Name
address (If differom f(orn local ion)
MA
ty own Slate lip Code _
Telephone Number
B, Pumping Recarc_i �-� �//�^
1. Date of Pumping Q .,a7ntit Pm ecs - —_-. ------- .....
Qa1e y u p Gallons
3. Component. ❑ cesspool(s) Septic Tank Tight Tank (� Grease Trap
Other (describe) _
4. Effluent Tee Filter present? �-] yeas - I,)o If yes, was it cleaned? res [) No
5, O-bserv�!'!,� Rion of cram r�
p annl purnped;
6. System Pumped By,
Dave T I n ey __----------_--_--_-- — ___._. Mass 1 AA 9 5 E Mass 1 A
t`Jame V/ehlclr� l irt3nse t`i.�rr�trrar
PgL@S n En(er rues, Inc
Cornpany
7. -ation where contents weft di5p03cd.
GLS
Signature of Hauler Dale
Signature of Recelving Facility (or agact) facility r(.ceipl) Cale
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