HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 444 SALEM STREET 10/21/2025 'Ow
Commonwealth of Massachusetts nof NorthA „
= ;u City/-Town of
- - r
System Pumping Record
Fora, a
DEP has provided this form for use by local Boards of Health Other forms may be used, but the
nformation must be substantially the same as that provided here. Before rasing (his farm, check with your
local Board of Health to determine the form they use, 'The System Pumping Record rnt.lst be submitted to
the local Board of He@tth or other approving aulhority within 14 days from -.he pumping date in
accordance with 310 CMR 15.351 -. y� -- - -
_ HOUSE. front
_.. .acky side ear)efit1 A. Facility Information aUIL0INC�. frontright
Important:When
(BECK. undar
((fling out farms 1 `tystein (._o(.,E]tl
on the computer,
use only the tab _ 1 r
_ 111
key to move your AdUrr�Ss
cursor -do not �YJ MA
useOlereluffl _..---.. ......_.__ -`4 '�-.. - ."' ._ .. ................_._._,. _._---- _.-..........._____ ...._._..,._..
key Cfdy/town Slate Lip Code
2. S ste Yi Owner.
10,
Name
rdrun `V�
Addross (if different from location)
MA
Cl yw own Stale Z17 Code _
_ _ -_ -
T�hune Number
B, Pumping Record
Date of Purnping �._ .. __..._ __.._.. 2. Quantity Pumped
C7ale Gallons
3 Component. r�esspoof(s) [� Septic "Tank [_] IcUrrt rank ❑ Greasy Tray
Other (describe)
4, Effluent 'Tee F-ilter present? [__.) `7'i s -_. Cto f yes, was it cleaned? ❑ Yes [_] tJo
5. Observed condition of corn )or�e�nt pumped
5 S e Purnped By
[-'va Tlnr Y Mass '1AA95E ass 1AD3'11
N, �7e Vehicle License Nunim >r
E3te ntrprises,
OPYY(Jdriy
l_ a or7.yvh7er cor7lerrts were distrosE I:_..,-- "
C3 3 D
sfc)nalure o4 f.er,,eivdng F2cllily (or att-ach (acili(y receipt) Date
-.._...
I,W) n4 doc- '1'1/1? Sys CM Pun')wng Record • Page; 1 Of 1