HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 22 RALEIGH TAVERN LANE 10/24/2025 _ ®nth
TO
Commonwealth of Massachusetts n vv r
a City/Town of
System Pumping Record aCr2 2025
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DE'P has provided this form for use by local Boards of Health. Other forrns may be used, but thy'
Information must be .substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Purnping Record must be submitted to
the local Board of Health or other approving authority within 14 days from -he pumping date in
accordance with 310 CMR 15 351
HOUSE � front back side rear left lF'tt
A, Facility information BUILDING: front back side rear left right
Important:When
DECK: under
filling out forms 1. System Location'
on the computer, �ry c
use only the tab -�L` .. 1_ - � --� Y.a..__. - -_.. -- - -- --- - -- ._...- -- --- ------ -------
key to move your Address
cursor-do not MA
usethe return ------_.__..._._ __ ___.__. ,_._ 'S✓_. _._._._ _ _----- -----___�—. --------.._--
key cilyffown Stale Code---- - -------
2. Syst,m Owner:
r�•r rnb -
-
lalan `�
.._-_. _--_-__-_-__--_— _..__--__ _..___...—
Address (If diPferenl from lor,allon}
M A,
Clly Town State r Zip Code
Telephone Number
B. Pumping Record
1. Date of Purnping -----__�---.._ _�--_--_._--_-- 2. Quantity Pumped'.
Dale Gallons --_---
3 Component. ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe) ------- ---- ----------
4, Effluent Tee Filter present? ❑ Yes 1 j, K''o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component p �mped:
�_
6. Sys -1 Pun-sped By
D e l inF y Mass 1 AA95E Mass 1 AD31
Na nF vehicle License Number
32P&Sat Enterprises, Inc
Company
7 Location where contents were disposed.
L 5 D C
- -
Signature of Haulef Dar - - -
ignature of Receiv ny aCility (or aIlar}i (arili(y receipt) [date
5for 4.dOc� 11112 System Pumping Recorr) Rage 1 of 1