HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 184 CARLTON LANE 10/24/2025 Town Of North
Commonwealth of MassachusettsaVer
OCTQC r 3 x 2025
( City/Town of
)n
stem Pumping Y � g Record
G o a/t
Farm 4 ed� B- �ef7t
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
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 Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351. -.- _.._---
_.____ HOUSE: front side rear of .c1r5i7t
A. Facility information BUILDING: front back sine rear, left right
Important:When DECK: under
filling out forms 1. System Location.
on the computer,
use only the tabkey °
curo -do your Addres�'� y �
cursor-do not W/ �,�* � � w t�' MA
use the return
key. city/Town State Zip Code
c2
2. System, wner: I
, - "
Name
reRu�n ticJ --
Address (if different from location)
MA
City/Town State p Code
Telephone Number
B. Pumping Record
1. Date of Pumping __._._---- ___-___ _- ---.-._ 2. Quantity Pumped:
Date Gailans
3. Component: [ Cesspool(s) ❑peptic Tank ❑ Tight Tank ❑ Grease Trap
[_) Other (describe) _ ___._ ____- _____..__ _ _-_..__- _ . ...._...
4. Effluent Tee Filter present? ❑ Yes L- Na If yes, was it cleaned? ❑ Yes ( ] Nn
5, observed condition of Garret pupped:
-_-�`
6. System Pumped By:
Dave TlneY_.. . ___..__. __ _....__ .. -.. _.. _Mass 1 AA95E Mass AD31Z
Name Vehlcie License Nrmta_
B-jtT9on Enterprises, Inc.
Company
7. Location where contents were disposed ..M.
GLSD — "
__._.. _ ------ _ _-...____.._.__-__ _----- ....._
Signature of Ha u
I Date
Signature of Receiving Facility(or attach facility receipt) Cate
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