HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 193 FOSTER STREET 10/24/2025 Commonwealth of MassachusettsOwn c , tVorth
s City/Town of n ov,r
Systet-n Pumping Record
� ..:." �1 F o r r 40
DEP has provided this form for use by local Boards of Health, A'alfkr be used, taut the
information rnust be substantially the s�ime as that provided here. Before Jr, � Eck with your
local Board of Health to determine the form Ihey use. The System Pumping Record rnusCP� submitted to
the local Board of Health or other approving @uthority within 14 days from -.he purnping date in
accordance with 310 (,,MR '15,351 --------
_____ HOUSE front back "PC
rea IrDf righ.
A. Facility information BUILDING: front Lack rear IeEt right
Important:When DECK'. Un(:er
filling out forms 1 Systen-) L-occatl r'1 t ,[
an lkie only
the( t) �7 Iti
use only the(at) .� 1. _. _.. _...--- _._.
key to rnove your !ddm s
cursor -do not fV1A
use the return ---- - __..
key. Y Slate Zip Code
�l Z. Sy tom Owner:
II Address (il difterenl from loca(lon)
MA
filly/Town Mate _ _............ .. _
r
Telephone Number
B, Purnping Record - - ,�
1. Date of Pumping � ...._� �� ... Quantity Purnpod G/afil
C7 a l f _-...-._.....
nS
3 Component (_._� CesspooI(s) _ Septic -rank -right Tank ❑ Grease Trap
❑ Other (describe) _ - --- . _ -
4, Effluent Tee Filter present? Yes .--.. No If yes, was It cleaned? ❑ Yes IVo
5 Observed condition of cornpon nt pumf 'C
-_... _....... ._....._._.. -___...__... r __.... ........._. .......,._ .._....-_..._.. ...___.__... ........ .._....._....._. ._._. ...._._ .........
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6 `'ystein Ptufriped By
Dave ri ey Mass 1AA95E ass 1AD31Z
_ ..
t Bai Vehicle License Number
�;son E=�r�i�ri�ris�s, Inc.
c««,Par,y
l "s cion where contents vver�'(Slsposed
GLSD'
Si u f o o t lauIe C7a
le
Slgnaturrw of RccEiv{nd f-srcllily (or g3ttar,h facili(y receipt) Cralc
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