HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 248 REA STREET 7/29/2025 _ Commonwealth of
; - City/Tarn of
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(CEP has provided this form fOr Use by local Boards of Health, other forms may be used, bul ll)c
information must be substantially the same as that provided here. Before using This form, cl)eck will) OW
focal Board of Health to determine the form they use, The- System Pumping F eeoro MLIst be s � y
�bmtit�t�d to
the foul Board of health or other approving autho ity w
0in 14 days from tie pumping date in
accordance with 310 CMR 15.351,
l 01U.S C fr-cent skis rear leftA. Facility r l�
Information BUILDING: front back side rear left rif,iii,
Important:vvl)on DECK: under
(Illing out forrns 1, System L.o a en:
on(I)e computer,
(Ise only O)a Cab
key to move ya(jr Add(ass
cursor-do not
use II)e relurn MA
i�ylTown ��
Yw Zip Code
,+ 2 System Ovine
s 101116
. Iarne
L:11
"d
Address (If different from location
MA
C ItylToen
State 'p Cade
if-
Telephone Number
. Pumping Record
1, Date of Pumping bale 2.. Qu2ntity Pumped;
Gallons
3. Component: essfa001(3) Septlic -fwanl [ Tight Tank Grease Traf)
Other (describe);
4. Effluent Tee filter present? [I Yes Na If yes, \Alas it cleaned" Yes No
S. Observed condition of component pumped:
6. System P Ijmped y:
"
Dave Tlney Mass 1 AA9 Mass .l 31
Name c C�1 u m b e r
-�i'�"n s _
w
kA�u
Company
7" Location where ,n(en1 WCfe 0 po5cd;
GL
ignalufe of Hauler
file
Slegnalure of Recelving'Facility (car attach facilily receipt) Dale
Wormkdoc" 111)