HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 244 DALE STREET 7/24/2025 c,! ommonvvcltl� of Massachusetts Massachuseits
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Town of
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Syste T7 Pumping R�,corc� 202
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infol:rm��I`ic>n rr7u§>C(e17ct1Esubskanli�illys foun for s{�e same a by WICal �n flrr�fa �rr>Vicfc:�r:S trFrc� Before r'nr�y t>c� t.s�i�, ta�'ti(I�e��'
( using this horrn check will', your
local BoaW of HealR o delernike the loan Pay WIT _l.l.e Sys(ern Panping Rewd fTWM beaMmilled to
Me &Cal Board Of Health or other appr wng ar.lthoNy with in 14 days Rom Me pumping date if)
accordance with 310 CMFR 15.351
HOWL front 00 icie rrL rif;ht
A. Facility Information BU(1.6TlNG� (rant back Side lr,��ar 'e' r rlfr7l
Important: Wizen DECK CSt r
tilling out forms
on he uler,
y tho
key(o move your Acfcirr,
uwsc>r .do nerl
use the return _ ....�� _ .....--- --- MA
ke.,.y. .itylrrrwrr :.Male lip C aelr
2. System 0uni rr
win. f A"
Addrr,ss (I(cfltierenf from Iocalion)
M A
City/T<w✓n _.. _-.._.. _ --_ .. _._ _....__ . .._..__.
:ywln lira,C,r7drz ....
-
rFlenwne Ntirnl>er
E3, Pur�nf�ing Rerort�i
1. Dale, of Pur-nping G)ai� ��� ---- 2.. Quan(ity f���irnl�,.)e 'i Gallan�� ._..__._._..._.._
3. Component: C:essperCl(s) ( Septic Tank ( ) Tight Tack Groase T(ap
EJ War (describe _._
4, Effluent Tee l"-dOr present"" � -' ? `rt,-- J rJC_) VI e �;, w�-)., if C I e,ar7t.7rS `,'e5
, ObseNed eonciition of cornponent pumped:
/l/e7✓yy`f l
6 System F>41r.rrl7ead By
Ga e llnr A
(Vl ass 1/ t1S 12ss 1�U311_
_... _ _. ._..___ - -----
<smaj vJaiYr lr Ir L.iCr"nsr; tJe1rnber
Cornpan}�
T LC)Caon where C'0r-1tCnt5 VVCrC dispus(Qd
6�-D-)
SK�rl21t1 �, I't��Uler O2iIC P d
SIc n Iurc ruf FtscclvintFacilll f,1 -- - —.- - -
.1 Y or attach �u.ilih rcr;ei�l f��ln
S(ornr4.dOc 1 tli2 System Purnpinr) Record Para 7 0l 1