HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 66 LACY STREET 6/16/2025 Comrmonwealth of Massachusetts 4117
114
;1 C'tyrTown of /I �
S
Form t4m PLIMping Record 411V 0
a
information rnu t be. tat..>stanhall the sarnr (
DAP ha., Provided flee; orrri for a.r<y€> k�� local fr. 3r EtY' trIon, t.tsin �o'�cl bui the
f. arrl of f7tPrc� be �,�;r-
Health to determine the form Ihr:,y use T Ire, to h learn Pumping FZr,co�'r�/ reel, eherl< with yr„atir
�t arc. -
local Board of ��e y,, f g d br; subrnllIed lc
the local Board of Health or other approving) auihoiity wilhin 14 days from the f.,-. 7ping (ate in
accordance with 310 C MR 15 3`)1
-C�
F3 t�L
A. Facilityll Inforniatlo - __. DING front back Fide nF?ear left ir�
t3l el`T n(,ht11
Important: When DECK: under
illling out forros 1. Systern 1-ocattioo7
on the cornputer, /^
e only thetab ._ .- 1.._4?!. Lr�--q5.. _/ _._
key to move your Address
cursor•do not �e�` '""'`
use the return __..___ _ . ._..._ .... . .,_ MA
key, City/-rOwn `iI")te lip Code
2. Systern owner:
1Y _
rrr�rn (�'t
Address (If different from location)
MA
Cltyrrown _......__.. .. _... 51aIe...��}" _..Q. . ._.._.q._�.+...c/�a r iP Cocfe
Telephone Number
B. Purn�irtg Recarci o^
'I, Date of Pumping TT-1 t5sl.. _�. ." _------------ 2. O u a n t i t y Pumped
Gallons
3. Component: Cesspool(s) Septic Tank Tight Tank ❑ Grease Trap
Other (describe): __.........._.__..____..---_-.__------
,i. Effluent Filter present? (.__] Ye`"r No 6 yes, was it cleaned? (_j Yes ( J f`!o
5, Observed condition of cornponent purnped:
6. Systern Pun-sped By
Dave T'lne Maser 1AA9SE ass 31'7
...._ .. _ ...._.... ......... ___...._ �.__ _ .. --- -
_ _....
Namr� t/ehlr.,lr, t i c urnber
kesnn nkerp:"r Inc
Company
71
on where contents were disposed:
( LSD
5lproalure of Hauler Oale
Signature of Receiving Facility (or atlach facility reu,,ipl)
l5forrn4.doc• 11112 Syn,lem Nraping Record Page t cl 1