HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 443 BOSTON STREET 12/1/2025 �f:)u
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t� Commonweallh of Massachusetts
City/ Town of ...
Systern Pumping Record
DEP has provlde,d this form for use by local Boards of Health, other forms may be ubed, but (he
in(orMation mu`'yf be substantially Uf)e, Sarne as U)a pCovided here Before using this farm, check with yow
local Board of Health to de;terrrrine, the loan they use. The Systern Pornping Recofd must be suUmitted to
the local Board of Health or other ralopmving authority within 14 days from she purnping data in
accordance witl-, 3 i 0 C MR t 5 3'r 1
HOUSE: rofn back side rear 'h�1t_..r
A. Facility Information 8 U I L 0 1 N G front back side rear left
DECK: under
Orr portanL When
flning oul fOrrrls l `7ysterrl l oc atlon
rxr the comptitor, � u 7 �
usv>only Oho Ia1,a .. .:_ _.-- -
_.._
Kay to move',your
Cursor do nol J / F
use the retuirr -._ - -+ � __` ._ -- __- NlF . .... _._ - .
key Chy/l'own_ S(ate Zip Code
2. Systen') Owner,
:T
f;
--t, Name
dr(5ss (II cSil'ir=,rn,�l frc,an ioca(han)
MA
Cdlyf r.,wn Slate 21f)Code
Tr lephone Nurnber
--._.— _.............. ----- .._,..._ ......... - --___..__...... __...._.—...— ....
B, Pumping Record
1, Cute of purnping Da_.e _ , 1..._._.----- 2. Quantity Pumped'. �
C,alirrns
Corciponent. -1 cesspool(s) ( ptic Tank El Tight Tank [.1 Grease Trap
Dl h e r (d c_s c r I b e)' _ -.._....... ... ..----.. .. ........._....___....__.._.—_._..,___......, ......._......._-_____.__.._._...._.. ..._..-----.-..—__.._____.-. ...._..-...
A. E.ftitient Fee Filter pfesent? ( ] `es F-'1" , If yes, was it c;lea,, d? [...� YF's No
Observed condition of cor17��C'ln >rll purni�ecf:
[✓(
(> ayste(I ,
umped E3y.
(),ave FIr-t Mass 1E>A05 Mass, 'IAD31Z
6V,�rrrPa Veh1cI(r LIc,P,nsc t rjr-nbe;r
B3;leson L.nIeiprisps, Inf;
Cofnpany
I L. (ior'I where come nfwr r, ed.
Si,nalum of Hauler -
(,2 l
'Icnaluru of idr.c eiving Facility(ear aoach facihty e
t D<elr.;
5torrrl4.doC 1'1112 Syslern PUrnpin(l Recofd f'gge i ()(