HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 295 REA STREET 9/10/2025 Commonwealth of Massachusetts down of NOrth Ana ver
City/Town of 2025
System Pumping y p g Record
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 OMR 15.351.-- ---- - — _---- HOUSE: front- -- "c4 'fide rear WT rip.1
A. Facility information BUILDING: front back side rear left right
Important:When DECK: Under
filing out forms 1. System l_oca ion:
on the cornputer,
use only the tab �= 1� J
key to move your Address
cursor-do not MA
use the. return --- V--- -- -- _— ___T __
key.
CityrFown State Zip Code
2, S Owner.
- `
Na e _
Address (if different from location)
MA
City(Town Stat � p Code
Telephone Number
B. Pumping Record,
1. Date of Pumping ----- 2. Quantity Pumped: — --- ---
Date Gallons
3, Component: ElCesspool(s) ❑ eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): ------____-___ .__.______---____----_---__ _--_-_- ----_-__-_
4. Effluent Tee Filter present? ❑ Yes [ o If yes, was it cleaned? [ ] Yes ❑ No
5. Observed condition of cc portent pum ed:
6. System Pumped By: -
arve^Tlridv ----- ------- --- -.... --- ..___ Mass
clei1iceNumberM ss 1 AD3, -- --- —
me
f7
at n Enterprises, Inc.
Company
7. Location where contents were disposed;
Signature of Hauler Date
Signature of F2eceiving Facility(or attach facility receipt) Date —
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