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HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 42 JERAD PLACE 6/16/2025 Commonwealth of Massachl-isetts pVel" City/Town of JUN -y - System Pumping Record � � �p�5 } DE P has provided this form for i_lse by local Board,,, of Health. Other fom-ts may b3' Ih inforf-nation must be substantially tyro sarne ab It al (>rovidcd r)ere. Before using lhi form), c i Ck With yt,.3ur local Board of Health to determine the form they use. The System Purnping Record must be submilted W the local Board of Health or other approving autho(ity wlihin 14 days from the pumping date in accordance with 310 CMR 15.351 - - ttOUSC front ack side re r eft ri)3ht A. Facility Information Cst.�l1 (�Iri<; font l�i�rk ,iris rear Ieh Important:When D ('K under (tiling out forrns System Location oo the compuler, use only tho lab — key!o move your Addross cursor -do not j '� M �� J�'"� �A �r- use the return ,—-- -- __. _ --- . — - _ keyyf('awn Slate 7_ip Code 2. System Owner _ _s> F Warne _..- ------- -- _ -- J\ - �, — --(I(-_.clll(er©._ - -----atio n--—) _ --- Address nl (rorn loc MA cit frown _ Y SIa1e Zip COdC' Telephone Number B, Pumping` Record r 1. Date of PurnpinC) — --. _._._._--_ .__. 2 Quantity Pumped Cale' GalIool; 3. Component'. ❑ Cesspool(s) Septic Tank Fight Tank Crease Trap Other (describe) --- 4. Effluent T`ee Filter p(esenl? El ye", I( yes, was it c,Ie;:)nEr--�I (�_] ti'eS [� o 5. Observed condition of cornponent purnped. 6. System Pljmped By: Dave Mass 1 AA9bE Mass 1 AD31 Z Warn[) /ehlCle r.ir,ens( Nurr)l.e.r RAgon En(erpri g,Inc. _ Company 7, Locution where contents were di5po3cd .r -- ._ ---- - _ Sign,lure of Hauler O j1e ---------�-- Slgnalure a(Rie, Iv Facility (or 311a0) facility re;ceipl) Ogle