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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 22 FULLER ROAD 7/21/2025 T Commonwealth of Massachusetts rawn a City/Town of Of/V©r'h4nd Over Systecr� Pumping Record F o rrn 4 AUG 1 2025 DEP has provided this fora—) for use by local Boards of Healtfl. Bq ¢� lay be used, but the nformakuon must be substantially the s�arne as Ihaf provided here. Be fb epp, '�4,rrm, check with your local Board of ldealth to determine the, foram they use. The Systern Rurr)ping Recor e submitted to the local Board of Health or other approving authority within 14 days from -.1ne pumping date in accordance with 310 CMR 15 351 —__.__ ___.__.. - _ _._.._.. -. . --- HC)USL: front back sine real left rif A. Facility InforrTlathoC1 aUILF)ING: front back side rear left rid Important'.When DECK. under (lkang oul forms 1 Uysiert-1 Location on Ilse cornputef, 4"" use only the(ab 1. K_[.. r key to rnove,your Aodro ss c u rs o f do not MA use Me f e l u i n _ _—__ key Cltylrown Stale ZipCode Iti� VTm^(l 2 13ystern Owner, rid "ICI --�nj nhm r� AUdress (I(UiPferanV faorn Iocalic>ri) MR Cily/Town Stele Zip Code Telephone, Number B. Pumping Record 1. Date of Pumping — � 451— __._-.- 2, (quantity Flumped clale Gallons 3. Cornponent. [__j Cesspool(s) Septic Tank ED -right Tank ❑ Grease `Trap F] Other (describe) _____ 4. Effluent Tee Filter present? [D Yes j No If ye,s, was it cleaned? ❑ Yes [_] No 5. Observed Condition of component pumper} 6. Syslerrr Pumped By Dave Fin y. __.. Mass 1AA, Mr355 ,ArD313 Arne Vehicle, license Nu B,�Ipsrin E..nterprises, Inc. r f,mp"iny l OL; r1 wfterP contents were dlSpUoE;'d17 ,lgnature of f IEst,ller Date SlynEature of f-�eceiving Facilely (or <�I(�scii L,u,ility fcsectr>t) (late - - 51trrrn4.d c ttllZ Systern t"cur Ping Recotd • Page 1 of 1