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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 230 GRANVILLE LANE 11/26/2025 Commonwealth of Massachusetts � pity/Town of _ � — ° System Pumping Record F o r n-i 4 k",-7"jT'L3 DEP has provided this form for use by local E3(jards, of Health, other forrns may be used, bul the inforrnation inust be; substanlially the sarne as lhaf provided here. Before using this form, check with your local Board of Health to deterrnine these forn'l they use. The Systern Purnping Record rr)ust be submitted to the local Board of Health or other approving authority wiIhin 14 days from -,he purnping date in accordance with 310 C M R 15,351 SICfE 57 left Gi A. Facility IrifQrrTlc7I©tl _._. ....._. .______. BUI�LOINC3. front hack side rear left rid Important; Whean DlllK, flll(ng out forms 1 Sys"te;rr L0ca n } /I on(lie cornpulor, /J/'/�r�l✓1 � r LISO orrly the)(at) .-.��., Pao u�'1 key to move your Addross Cursor-do rrot use file return M q key. Illy/Town Stale Zip Code y5tef7 Owner �r rb ...... . . . _ Addross (if ditf;resnt I(orr7 ior,„atlr,)n) ... _ MA CH /Town____ --p Co d-e-._..- y SIaVe � Telephone Nurnt)er -____ -... _.._.... _..._ �..._....------- ,._. �. e ._. B, Pumping Record _ Date of Purrtpinr4 _...____ __. 2. Quantity Pumped ----- C7ale Gallons 3. Component s3 4 esspe��l(s) ����tGc Tar,4<, �._� Tight 'Tank �1 Grease Trap [] Olher (descril,e) _ _.____ .. _._.__ _ 4, Effluent Fee r-iBter present? [_.) Yes _. No If yes, was it Cleaned? El Yes [.� No 5 Observed Cor�iriltion of c,r,rrt)of enf ptlr(1 is- ` strem '(,fn"tpe'd by w [have F!r)e}y Macs lAA95E M ss 1AD31Z �7arrttt .�-�'� Vehlr,le l_Ir.,nnse Niirrrbr�r L,ati"on y t_c Ir e, ce , er s�CA signslurn c ( ti c.ilcr D a ,lyiralurc. ofF;t.CFivin f=uciiity(oruglily reacr;irrl) Date (orr 4.t90C t'1112 Sysler'n Pumping Record Page 1 )f 1