HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 26 LONG PASTURE ROAD 6/6/2025 TOWn of IV Qrth An
doer
` \ Commonwealth of Massacr)usett s
City /l-own of
�' _ - SUN Z 6 2025
System Pumping Record
7
F o r r71 4 H ''Iti, Depcj
rtmen
DEP has provided this, forms for use by local Boards of I ieallh. O(her forms may be (used, bu((:,
infon-notion must be substantially the sarne as 111st f_>rovidr d horo. E3e(ore using Ihis form, check witft you(
i local board of Health to cieterrnine the form lhey use. The System Purnping Record crwst be sUbMifled to
the local Board of health or other approving, authority wilhin 14 days from the f, urnping date in
accordance with 310 CMR 15.351
I
HOUSC front )ack sloe real eft riphT
A. FacHify Information BtJILDINC) front brick side rear left rii{r,t
Important:When DECK under
(Illing out forrns 1. Systern Location
on the computer
rise only tha lab4----
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key(o move your Address
cursor - do not +,�
use l h e r o i u r n _.-__ ✓ M
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key cityffown ol<+Ic; Zip Code
1 2, S ern Owr ter:
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rrran f
flddress Q(differ�nl from location)
MA
Clty(Town Slate / Code
CO
Telephoi7e Number
B, Pumping' Record
1. Date of P G,rn p i n g --.—____ _ __._.__.___-- > (�u a n t i t y Pumper-1
: -
Dale (gallons
I Component'. ❑ cesspool(s) Septic "tank [_� Tight Tank ( Grease Trap
M Other (descrihe): ---- ------_ ---------
4. Effluent Tee Filter present? [._.) Yes ( Igo If yes, was it cle aneri? ( ) r'es [j No
5. Observed condition of component put-nped:
6. System Pumped By:
Dave Tlne
Mass 1fi a95� ass 1 AD
----y— ------ - --- — - -- --- — --
�lam Vehlcle (_ir-eose HUr ,r ----
Bafeson �n(er rises, Inc
Cornpany - - -
7• lion wtlere contents wren disl7vsed:
GLSU
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-- — - -
Signalure of Mules O1ie
Slgnalurp of Recelvint} 4 <.+cllity (or atlac,Ya (arlliry (r.er,Ipl) C�nle
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