HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 100 JOHNNY CAKE STREET 11/21/2025 r Commonwealth of Massachusetts
City/Town of
r 7
S Yt l-n Pum inc Record
F o r rri 4
DEP has provided this form for use by local Boards of Health, Other forrrls may be used, but the
inforrnalion n'1ust be st,ibstantially the same as that pcovlded here. Before using Phis form, check with your
local Board of Health to deterrnine the for r they use The Systerrl Purnping Record rYnust be submitted to
the local Board of F-iealth or other approving authority within 14 days from -.he purnping date in
accordance with 310 C M R 15,351 --
__.w.._., HOUSE, front back slue ea le if;
A. Facility Informatiot-I BUILDING: front back side rear left rig
Important: Whoo DECK, under
oi.ri forms 1. ySlGrl'1 atiOrl',
orl(tie
an 1175 camputeir,
use only the lab
key to move your Address
Cursor -do rfo( f� 7
USE, the; re.(mn --. ..—,- _ C_�.... .� � MP
key C Hyf o-n stale Zip Corse
2, Systern (Owner:
(l,/�� Cab � w..---°-- �� ._••-�—
N a WP7 e _
r ,
Address It different from loc;atign)
MA
11p Code
Ily/fawn tale
reler7one Nurnbcer -
_ ._.............._...._._,.--- ._—_— _ .__._.___._._.....__._......__..
B, Pumping Record
1. Date of f=urnpin9 __ 2. Quantity Pumped
Date Gallons
:3. Component, [_.D (>,sspool(s) [ eptlr "i'<.er�rk (.,._) Tight Tank [-] Grease 'Trap
CC 0(her (describe) ---_ __..__._ _._._. _.__,
4. Effluent 'Tee Filter present? ( ] Yes No If yes, was It cleaned? El Yes 0 Ivlo
5, observed condition of c.omporent pumped /
ZI
6 'ystern gun-ipecal By
E vre Ti cry Mass 1A�9 E Mass 1AE�;'11
._ -- -
Nar7�r, VehicleLIcensr nber
Balm sori EMerf)rises, Iric;.
co+ pary
7 I,ccJori vhe-( : C� s were; disposed
Gnu>lp,-
Signatufe of Haute( __. Date
slgrea ire of Receivlrsg Fe7Gilily(of ali<r<,h facility fr;ccipl) r)31C3
t5lo(m4.doc, 11/12 ,`system Pumping Re(,Qrd - Page 1 C.)f 1