HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 138 OLD CART WAY 10/24/2025 Commonwealth of Massachusetts
Own of City/Yawn of NO 1 OVer
a S stem P y umping Record
'Yr' Form OCT 2 2025
DEP has provided this form for use by local Boards of Health. Ot 4,r p may be used, but the
information must be substantially the sarne as that provided here. rm, check with your
local Board of Health to determine the form they use. The System Pumping MeNaO&OrIfulcmitted to
the local Board of Health or other approving authority within 14 days from the pumping date In
accordance with 310 CMR 15,351. -- sl rear- left `(rip
HOUSE: front a rear left r'(�
A. Facility Information BUILDING: front backant
Important:When DECK: under
filling out forms 1. System l ocatl n:
on the cornputer,
use only the tab �..� _
key to move your Address
cursor-do not
use the return ___.__.______._.__.._,_ T_1L. ____— Cr , __.__ __._,_.._ M
key. City/Town State Zip Code
rti�Q—
Name2. System Owner:
iarcrnn f�'`i�
Address (if different from location)
MA
CityC own State a Zip Code
Telephone Number
----_ ---.___ ___.____—_ _..---.-
B. Pumping Record
1. Date of Pumping D at _....__-_ _._....__ 2 Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) (Septic Wank ❑f Tight Tank ❑ Grease Trap
❑ Other (describe): _...__. ___.___ _ __-.___. .___.__._ ._____._.____.__.____---__._--
4, Effluent Tee Filter present? ❑ Yes (. No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of cornponent pumpe
5. Sys em Pumped By:
La e Tlrley Mass 1AA95E Floss 1A( 31Z
-_-_ _.... ----__ ._. -_ ._ _... _.-- _____ . .___ —.__ _..-._..
Name
Vehicle License Nurn ,E r a'
Bateso> nterprises_Inc
Corrlpany
7. Location where contents were disposed:
11�-
-,LSD
Signatures of Hauler Date
Signature of Recelving fLLacility(or attach facility receipt) Date
t5form4.doc- 11112 System Pumping Record -Rage 1 of 1