HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 280 CANDLESTICK ROAD 9/24/2025 I
Commonwealth of Massachusetts TO
Wn ofNOhAnU
over
r = City/Town of
y ern Put-nping Record SEP 29 2025
V Fort rt 4
C EP has provided this fora, for use, by 4ocai Bowds of Helal'PW r . i� be; used, but the
Information must be substantially the sarne as that provided here;, Befor� trrr, check with y
local Board of Health to determine the form they use The System Purnping Record rnust be submi tee
the local Board of Health or other approving authority within 14 days from the punrping date In
accordance, with 310 WR 15351
MOUSE, front ac.k side rear Ief
f
A. Facility Information BUIt.DNG: fr,crrh` )ack sine rear Ief
DFCK: uIIdf--�r
r Important: When
( ling out roans y
n 1 St�CTI _C7( c IlJ
use only On the aorriautaf,
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4 r ACditdyfrTr kc move your
cursor-do riot
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USG t1G rotor S � p Code
key _...__.._....,... __.._.......
r
r 2. SystP Owner:
r (r1 irYVP
\\ c
Ac}dro.a (IF rJiNeren! from location)
MA
ik /Town `7fn}
e ....P.. Lip Code
Telaph-one Number
B. Pumping Record
Date of fuE.arr'tpinr 2 Quantity F'tr,raped
� C,)<ale C2afans
Component: ( ] Cei;Spool(s) _ Septic "tank (.�.) Tight TGank. (� Grease Trar:;
Other (describe)
11 Effluent Tee Filter Present? [__� Yes (- If yes, was it cleened ? [__.� Yes
5. Observed condition of cornponent purnP ed:
G. Systen-x P )roped By -
Dave TIn€= Mass 1AA95B Ma s 1AD31-
Na vehicle, License Nurnher
� f3atesorl Frlte7rp6sos Inc
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ny
7 LcrcC Ion vvherf- ltens VVeI ds�lusca d:1
GLSS
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Signhwr(s of Hm,jie Dato
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Signalu(e of r, cc,ly n I �c;pity {r�r attacr7 (ar;ilily re�c+al:,l) Date —
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t5form4.doc- 11/12 System Pumping Recor(a - f'afte 1