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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1276 SALEM STREET 6/25/2025 Commonwealth of Massachusetts 417dover �i City/Town of -- SUN 3 0 2425 System Pumping Record Form 4 -'a{ ' L)epa rttnent DEP oval Boca drmust bee subis s tant ally trm for hb\sa�rne <_cal �,o'h7jls of>rovi dedthr,,rerer f3nf fore usm y Ni used but the y f� g this form Check with your r of Health to determine the form they use. The Sys(efT) Pumping RE2cord must be submitted to the local Board of Health or other approving authority within '14 days from the pumping date in accordance with 310 CMR 15,351. __.___._ HOUSE fror bac side re 1e right A. Facility Information BUILDING, front back side rear lefi rff!lht Important: When DECK. under tilling out forms 1 System Location: on 0e 1lrar, u Only onlyly the lab key to move your Ad r©ss cursor-do not I MA C� Use the return �Lt/� __ -- _ .__. _ - -------- key. City/Town Slate 'Zip CodeIdGII-D 2, System Owner: ...------------ Name Address (If different from location) MA --_ Clty/Town Stale Zip Code --- C'3-tom- -5` Zy-- — Telephone Nurnt,)er .. .......... Pumping Record (�- 5-_.__ --- 1. Date of Pumping Gate - 2. C�u2ntily Pumped. - Gallons 3. Component: ❑ Cesspool(s) ( Septic -rank ❑ 'Tight Tank ❑ Grease Trap 0 Other (describe) ----_..------------- --------- ------ _—. ---- -------- ---- n. Effluent Tee Filter present? F Yes 1 No If yes, was it cleaned'? ( ] Yes [ f40 5. Observed condition of component pumped: 6. System P�fr-nped By: Dave Tlne ss 1 AJA95E Mass 1 AD31 Z y-------- --._ ----- - ------- --- — -- Name Vnhlc.le LiCr)r umf)If PMegnn lnlar rrigog, Inc. Company 7, t_a ation where contents were disposed: �L . ------ -------- Signature of Hauler Dale Signature of F�ecelving Facility (or a(lach facillry rs�reipl) pale Wom)4.doc• 11112 >ysIerri Pumping Record Pale 1 01 1