HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 39 GRANVILLE LANE 5/30/2025 1Own
Of'V"th A
ndaVer
� \ Commonwealth of Massachusetts
City/l own of SUN
1520
i s 25
Sy
stem tem Purnping Record
4 Form c�` '°�
, Depart
Ment
DEP has provided this form for use by locaal Borards of Health, Other fo(n a may be used, but the
i information rnust be substanlialiy the sarne as (hest provided herd. Be(ore using Ihis form, check mil) yom
local Board of Health to determine the for they use The System Purnpinc) Record must be sutarTMed (0
the local Board of Health or other approving authority within 14 days from the purnpincg elate in
accordance with 310 CMR 1.5.351,
HOUSE: on back side rear left f 1.
A. Facility information BUILDING: front back side rear left rif;hl
Important;When DECK aClCr
(Kling out forms 1. Systern Location'.
on the corrlpulPt,
use only Me lab
key to move your Address
curses - do notuse the rolurn
key, City Town -- - -- Slate -- - Zip Code --
2. Sysfern Owner:
Name
Address (If different born location)
MA
Clt Clown y state +7 {� Lip Cody.
lclephoi�e Numbre.�r �--__._-------_----__---
_____-.__._.__._____-.. _.__._....._.- �_._..-_-___-_..._ __.._-._...... _.....____.__._.__.__..._.- ..__...._.._._ ....____,-..,_...---..._, _...__....._...—_.__._..._. -._..___.__-_...._...
B. Pumpind Record /
1. Date of Pa)rnping 0�i .__.-- 2. Quantity Purnpeo
/ gallons
3. Component'. ❑ ccsspool(s) [/1 Septic Tank ❑
Fight g Tank ❑ Grease Trap
F3 O l h e r (describe): __..____ ____._ _.-_.__...
4. Effluent Tee Filter present?/ Yes ❑ I\JO If yes, was it cle,)ned? ( Yes [] No
5. Observed condition of cornpponcnl purnped 1
----------
6. Systern Pumped By:
Gave Tlney Mass 1AA ass
_..-_
arne Ve,hlcle l.�ceosc, Nume
B�feson En(er rip ses, Inc.
Company
7, LC �ation where contents were disposed.
psigFln�71tjfp
<oHa(j�lei Uale
Signature of Receiving Facility (or attach fadli(y (eceipi), Date
If)lorm4.doc, 11112