HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 194 RALEIGH TAVERN LANE 7/18/2025 Commonwealth of Massachusetts OW/7OfNorth
City/Town of
An�o�,�
System Pumping Record AUG
DEP has provided this form for use by local Boards of Health. Other forms�r�` � d but the
information rrlust be st.tbstanliaiiy the same as that provided here. Before using fhiS * ck with your
local Board of Health to determine the forrn They use The System Purnping Record rnust be submitted to
the local Board of Health or other afrp oving authority within 14 days frorn she purnping date in
accordance with 310 CMR 15.3.51
____ -
A. Facility Information BUILDING front back side rear Ieft rip
IrnpUrtanP: WI'rerq
EC'K: under
ruling oW forms 1 Systerr1 Location:
on the compuler,
use only the lab _._._--------- ---.. _.. .__ ...
key to move your Arddross c/
cursor do not
use lhe, retulrr
key CI,y(rown Stele Zip Code
fir_._........._, 2- y
�7 stefi1 0wrier
Ili r
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Addrr�ss (if diff2r�n( (torn loc,alipn)
MA
CI(yrrown I a t e, zip cede
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Telephone Nufnt>ejr
B. Pumpincg. Record
1 Date of Pun"Ipinc / .._._. _.plc , --_-.._�Quantity F unlpec9.
Gallons
3. Cornponerrt: Cesspool(s) Septic `tank Tight Tank ❑ Grease Trap
Other (describe) --___
.1. Effluent Tee Filter present? (--_) Yes ( _ tc� If ye,s, was it cleaned? [] Yes 0 No
5. Observed condition of rota ponenl numl,)e }
6. System Puri-1{.)ed By
Gave, 1inrq Mass 1AA95E ..
ass 1AC7
1�1,�rrrrr VreY�ic.lr, l_Irense h!u
Bea eson E n(erC)risps, Inc.
Ecrrnfaany
7 i_cr 'slion where contents were disposed
C31 C D
`ruln�lurF„ of Hauler Dale
Slyrrtaloue <.>f ftr,c;wiving f=raci{ity (or ,ilt<n,lr (t3riltly rerr,irst) Date
l5lorrn4.doc• 11112 :lyslern Purnping rtr:Cord Page 1 of 1