HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 119 LIBERTY STREET 12/4/2025 Corm=wealt of Massachusetts
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City/Town of
S stem Pumping Record
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Fort 4
DEP has provided this fora" for use by local Boards; of Health, Other forms may be used, but the
nformatlon must be suL)stantially the: sarne as Chat fsravlded here Before using [his form, check with your
local Board of Health to determine the form they use The System F'o mpring Record rrrt,rst be submitted ro
the local Board of Health or other approving authority within 14 days from -he purnping date in
accordance wltll 310 C MEN 1`r 351
HOUSE: front rear rif
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A. Facility Informatior" c-st.nt_D1NGC front back side rear I-ft rig
lmportant;When DECK: under
filling out forms 1, System t oc- tlon
on the cornputer,
use Ooly the lab
key to move your Aa
cursor du nol / �4 PV1A
use I h ea re l u i n -1-1 -1--1
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Q, Pumping Record
1. Date of Purnping Dale "--.-- 2. Quantity Pumped ��a /_ �
ons
3 Cornpor)er7t Cesspool(s) ? e p t i c Tank ❑ Tight "Tank Grease Trap
[_) Other (describe) r
4. Effluent Tee Filter present? `ram "� No If yes, was it cleaned? °`Yes 0 No
5 Observed "0 difiCrrt of cot-nponew pumper4:
G_ Sy teein P r1pr:d By
w
ave Eone_Y ..__ Mass1AA95E Mast 1AD31Z `
Vehicle L,censo N� jrn er
son Enterprises, Inc.
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Slgnairi(e of Hauler Date
ralgnalurc (;7( Receiving Faciloly or :711a7r,1� (tacilify rcCr;l(>l) C.7krlc;
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