HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 326 FOSTER STREET 7/26/2025 Commonwealthof Massach�,.jsetts
C'ty/Town of
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Systern Pum,ping Record
DEP" has provided this form to use by lccai Boards of Health, Other forms may be used, but (he
information must be substantially the same as that provided here.. 9efbre using Ihis form, CheCk with yaLJc
local 'Beard of 'Health to determine the form they use, The System Pumping Record Must be submihed to
the local Board of Health or other approving authori(y within 14 days from the pumping date in
accordance with 310 CMR 15.351.
Ii01U_ E: (f(6nDack p le side re n t
A. Facility Information Bul t_DING frontback side rear left q)l)t
Important:Whan CHECK: under
filling ow forms 1. System Location:
on Hie computer,
Use only lha lab #
key to move YQur Addres
cursor-do not CV1A Z,41',�4PIT
use (l)e rhlurn �.
i lyl°T n r~ti �.,..�
key, s l a m_.,.,....
�'�p Cody
f
tern v�'rler:
r leb
1•.
Address(If different from location)
M A.
cftyfTown stale Zip Cede
Telephone Number
Pumping Record
1. Date of Pumping � ° ,.
ale 2• Qugntlty Pumped Gallons
. Component: Cesspool(s)
Q,,S,,e!rP"t i c Tank 'Tight lank Grese Trap
ry�,
Other (describe);
4. Effluent Tee Filter present? - Yes It yes, wcas it cleaned' ZYes [� No
5. Observed condition of component p mped.
. S rve
Piimped By. _
Dlne y Mass 1AA 5E Mass ' 1z
Na )8 Vehicle License Nur-)b r
cn l r TM, Inc.
Company
7. Location wheie. contents were fl5po,5c ,
C
Signature of H2uler
Slynature of Recelving Facility (or attach facifl(y re.®�.
.. .cewpt}
Dale
Worm4.doc, 11/12 System Pumping Record °Pnop. i nt 1