HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 102 SPRING HILL ROAD 11/21/2025 Commonwealth of Massachusetts
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City/�Towr� of
S stern Pumping Record
ForrT1 4
DEP has provided this fern") for use by local Boards of lealth. Qther farms may be used, but the
information (mist be Substantially the sarne as that provided here. Before using this fort"n, check with your
local Board of Health to determine Wie furl-n they use, The Systern Purnping Record must be subrnitted to
the local Board of Health or other appoving auPhority wiChin 14 days frorn -,he pur�nping date in
accorcdiafice with 310 C,MH 15.351, ----
HOUSE. front a side rear eft rlf,
A. Facility lnforr7 abort BU(LDiNG: front hack ride rear Vert (ig
important:Man DECK: u n d e r
(liking oul (orris 1 System Location.
on the computer,
uae only lha tab � F.� � <I�,��
k5y to move; your Ad rr s
rf.rr cp - du rent (VIA
use i I i e return .-_. . y '�� -44v —--.._.--- .__ . .w-_.._... ---- ------
key. C(iyr"1 On Stale ZIP code
2, Systerra Owner:
1�- , 1 Narne
Address (if differenl frorn location)
M A,
C,fl Town 71a1 li, de
_
Telephone iJucrofde! ______.__,,..,
_-_. _
B, Pumping Record
'1. Date of Purnping ... _--- ----..----- __.. 2. Quantity Pur-nped -
Dale G allons
3, Ccrnr7oncn( [_.� essP0a((s) epter lank [ Tight Tank Carease 'trap
Other (describe)
4, Effluent Tee Filter present? � ) `� [..] NO If yes, was it cleaned? - Yes
5 Observed condition c>�(�;,qrnPone���Y)ped:
......... _ _ _ _.. ....
6 System Pufi-)peci By
Mass 1AAJ5E Mass 1AD311
NarieEY Vehicle License Numb r
B2leson D)terl-)ni es, ln(..
C<rlrrfxttny
7 t <n< ,� `r� " wv n«rs.re cr:�rlCr,I�ts were diss�f,>e>�,e;t:f
t`
_..
Slgnalmo cal Hanle( t ate _ ._
_... _..
>lynaturc of F1ec+ivincl Fr.icility (<�r 7lIr7�;t� Lsfali6y recc,ipl) Dale __ ........_
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