HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 178 BRIDGES LANE 6/6/2025 Of North
A/7dOVer
\$ Commonwealth of Massachusetts SUN
City/Town of 2025
System Pumping Record 1 � r�
Form 4 partrnent
DEP has provided this form for use by local ROOCds of Health Other forms rn�1y be used, but (i)e
information rnust be substantially the sarne <1s that pf0 vidcrJ he-.r(,. Be.lore using this forr'n, check with your
local Board of Health to determine the form they use. The Syster-n Pur-nping Record mUst be sUbmitted to
the local Board of Health or other approving aulhorily within 1I1 days from the puroping date in
accordance with 310 GMR 15.351,
------ HOUSE front bac d ear let Sht
—.--------- ---_... —--- -A. Facility Information Bult_DING front back side rear ief-t right
Important: Whon BECK: under
nlnng OW towns 1. System Location.
oo the,computer,
use only the 1ab1�1'�e_r
----- JJ _ —— __ — .. _ -key to move your Add(e s
_ ---
cursor-do nol use the return ------ MA
--. .--- __y------ --
key, ity Town Slate Zip Code
f ^�
2, Systern Owner:
Name
Address(If di(ieranl (corn location)
MA
y own Stale lip Codr.
_ - Y_W Y _ -- - - -- ---
1'eleph�o n e Number
B. Pumping Record
1. Date of Purnping - IIA --------- 2. Qu�anlit Purn ped. /
y f
Dale o I I o n s
3. Component: ❑ Cesspool(s) Septic Tank ❑ right Tank [-I Grease Trap
[f Other (describe): ---------------- ---
4. ffiuenl T'ee Filter present? [_� Yes hJo If yes, was it cIe,�)necf? ❑ Yes C] fvo
5. Observed condition of mponent pumped:
6. System Pumped By:
Dave Tln_�y Mass 1AA95E Mass 1AD31
Hama vehicle license Nuns e
Bateson Enter rino , Inc.
company
7, ca it where contents were di5po3cd.
GLSD
Signature of Haulei Oate
Signature of Receiving Facility (or attach facility rr,ceipl) Date
Ifilormzi.doc, 11112 System Pumpinq Hlecoul Pann 1 n1 I