HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 268 RALEIGH TAVERN LANE 6/16/2025 Commonweal �hA��®V�r
.w Commonwealth of Massachusetts
a City/down of — SUN 2025
_ ( System Pumping Records'
-/f Form 4ap
DEP has provided this fom") for use by local Borardrs of Health. Other forms may Ine used,,��il�v,
information must be substantially the sarne as ll at provided here. Before (.)sing This form, check vvifh your
local Board of Health to determine the roan they use The Sys fern Purnping Recow rnt.(st t)e sun tleU la
Me local Board of Health or other approving aulhoiity within 14 days from the pumping date in
accordance with 310 C M R 15,351.
H 0 t J S F front: back de "esr left rif,hl
A. F@CIlI_ty Inforr-nation BUILDING front hack ,isle re.ar Ieh right
Important:When DI-C'K (-(rider
filling out(orms 1. System Location
on the compuler,
use only the lab ' ----
key(o move your Address
cursor e do not .� f�A
use the return Ci S��✓ --.-( _�_- y
----
key. Ciy/I'own Siatc; "Zip Code
2. System OwnerName
Address(If difieroni I(orn location)
MA
C It (Town 3
---- -------------_--- ...-- , ----------- ------ _--------------._.__ _
y ---- ------ 1c res lip Code
5ar�- --
Telephone Nurntaer
----------- ---- ---- -- - ------------------- _. ........--- -- -
B. Pumping Record `�,
1. Date of Purnping Dai � ------- 2. Quantity Pr.,mped --- G----- - -
Gallons
I Component'. ❑ Cesspool(s) ( Septic "rank (_� Tight Tank Grease Trap
�) Othe( (describe) —_ __.____ (.___.
4, Effluent Tee Filter present? (.-f es ( No If was it cicaned? C ] Yes [) No
5, 0t)served condition of component purnped
--- �dr MON
4—
6. System Pumped By:
Dave Tlne Mass 1AA95E Mass '1AD
Namo Vehicle l_iCensq h7urt7
---- ._-.
Uwn Fnferprisos, Inc
Company
7, L II where confonts weir di5po5Cd.
LSD
Signature of Hauler dale —
----_.----- ___-- _ _ -____ _-_ _..___ -.____
Signature of Receiving Facility (or allach facility feceipt) Dale —" -
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