HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 427 SUMMER STREET 10/27/2025 TO Win
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Commonwealth of Massachusetts over
City/Town of OCT
stem Pumping n R 1.2025
=` Record
< � Farm 4Health
DEP has provided this forn-t for use by local Boards of Health, Other forms may rII939 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 -.he pumping date in
accordance with 310 CMR 15,351 -=
HOUSE:U S E. f r o r�t stile ear E,ft right
A. Facility Informatior7 BUILDING front ra��ck side e r ,°Z right
Important:When
DECK: under
filling out forms 1. System Location
on the computer,
use t only the b
keyto move qur Address
cursor-do not
use the return --- ----_ _..__Y_.. r = fVA
C l l l r ow r7 T - - —-------- --- ..._.
key y Stale Zip Code
2. Sy St r1 Owrrer:
a - Name
rerwn
Address (if different from location)
MA
C Vly Town State -
Zip C de�...-
y
-Feph 'Number -
B. Pumping Record
1 t I y p - =
1. Date of Pumping —ate --- -- -- ----- �, Quantity Pum ed'. Gallons ----
3. Component. ❑ Cesspool(s) Ej 'Septic Tank ❑ Tight Tank ❑ Grease Trap
[� Other (describe): - _.___
4 Effluent Tee Filter present? (_] Yes [ '<o If yes, was it cleaned? ❑ Yes [] No
5. Observed condition of component pumped:
6. Sys m `r'npc1 By
Da e Tine Mass 1AA90E Mass 1AD31Z
Narn Vehicle License ember
Batesort Enterprises Inc.---- --'�
- tiort.w f tents were disposed
LSD ,
Signature of Hauler Dale -
Signature of Recelviny Facility(or attach farihty receipt) Cate --
15form4.dm- 11112 System Pumping Record - Page 1 of i