HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 42 FULLER ROAD 9/18/2025 � i Commonwealth of Massachusetts
ndOVer
SEP 1 Zp5
==r City/Town of
System Pumping Record
Farm 4DeParhent
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 CMR 15.351 — ----
- HOUSE: ron` ac eight
A. Facility Information BUIt_DING: front back side rear left right
Important: When DECK: under
filling out forms 1. Jyster71 Location.
on the computer, )
use only the tab "/
key to move your Address
cursor-do not
use the return —____ __`__ _ __. 0_ __. ___ --- -. MA
key City[Town state Zip Code
2. Sy to Owner'.
1 4 Name ---
r
- Address (iF difiersnt from location)
MA
Clty[Tovdn State Zip Cod
Tee h Q
ne Number
B. Pumping Record
1, Date of Pumping Date �__ __--_- 2. Quantity Pumped.
Gallons
3, Component: ❑ Cesspool(s) (Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe) -_______--_ .__-_._._ ..-—_-- .----____---_--._._.__-___—____..-- _-____._.
4. Effluent Tee Filter present? 0 Yes o If yes, was it cleaned? �_] Yes ❑ No
5. Observed condition of component n bed:
6. S stem Ptamped By'.
ave Tlne Mass 1AA95E Ma 1AD31Z
Uarne Vehicle License: Number
teson Enterprises, lnc.
Company
7. Loc tion where contents were disposed:
C
___-- D-a_f e
_____--___--
Signafure� of Ha�.rler
Signaturef Fl
oecelving i-acllity(or attach facility recelpt) Date
t5form4.doc- 11112 System Pumping Record - Page 1 of 1