HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 235 CANDLESTICK ROAD 6/6/2025 0 /7 off
VorthAndOver
Commonwealth of Massachusetts JUNxs
City/.l_own of
a25
_ System Prim in _Record � �
p C,p rtmeri
DEP has provided (his form for use by local ftoords of Heallh. Other forms n7ay be used, bul the
inforr-nation r-nust be s>ubstanliahy O)e sarnr� as, that piovidod here. E3efore using Ihis forrn, ChrJok rtiilf� your
local Board of Heakh to determine the form they use. Tt1c Sy Stem Pumping R= 2cerd ml.ls( be submitted (o
the local Board of Health or olher approving authority within 14 days from th'e pumping date io
accordance with 310 CMR 15.351. ------------ ---..___ ---
HOUSE fron back side rear lef, right
A. Facility Information [I tj I L D I N front back side rear left rif,,nr
Important:whin Dl CI< under
titling out forms 1. System location
on the computer,
use only the lab
key lq move yqur hdd ess cursor e do noI (rJ V f/1 V — fVA
use the roturn 1—_ _
key. City/TownState Stale Zip Code
� i 2. System Owner:
ri��t rya
Name ---
rrr�rn
T— _—_ — - -rn-"
— .------ ._.. — ---_...------- —--- ------------ ---------- --Address(I(diHerenl morn location)
MA
Cil_ __--------_..___..
/T awn _.____...___._._....._-___._.._____....._..
Y Stale _7Zip code
telephone Niir7iber
B. Pumping Record
1. Date of Pumping ._
p g Gale _.__. 2 Quasn(ity Pumped —1`
Gallons
3. Component: Cl Cesspool(s) Septic Tank ❑ Fight Tank ❑ Graase Trap
❑ Other (describe) -- .... _... _ ..- _ _. --
4. Ef-fluen( Tee Filter present? [._) Yes Lr< i\jo If yes, was it cleaned )
5. Observed condition of cornponen( pumped:
6. System Pumped By:
Dave T i n ey —-- Mass 1 AA 9 5 E ass '1 A D 312
Namo VehlCle t. censo Murnber
Uggon Fn( rMri og, Inc.
Cornpmy
7, ho"akon he contents were disposed
GLSD .�
Signature of Hauler Dale
Signature of ReceIving Facility (or attach facility receipt), Oate -- -------
t Jforrr)4.doc' 11/12 syslem Pnrnmon P""„i r--, ,