HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 24 DEER MEADOW ROAD 10/31/2025 OWn Of
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Con7monwealth of Massachusetts
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System Pumping Record
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DEP has provided this form for use by local Boards of Health. Other forms may be used�Pttthe
information must be substantially the sarne 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 Vocal Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR --- -------- _.. ._.... _.._.._ ._.-
_ HOUSE f r o n b a c S, s i d e rear left rip 11 t
A. Facility Information BUILDING: front back side rear I�ft rig, "
Important: when DECK: under
filling out forms 1. Sy tern ati on:
on the computer,
use only the tab
key to move your Address
cursor-do not f, May
usethe. return _.----__.._.-__._.___.. _..___ ._ -E-_._. �1__ ---- __ _..-..... _. ._.._._. ...._ _�.____._.---------------.___ --__-_-
key. City/Town Mate Zip code
j -- 2. Syst m Own r:
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Address (if different from 8ocation)
MA,
City[T'own St - -- Z' ._.
NumberTelephone
B. Pumping Record ,
ON
1. Date of Pumping ___-_ __-__ __ .._ 2 Quantity Purnped
D a I e Gallons
3, Component: [ f Cesspool(-, Septic Tank ❑ Tight Tank El Grease Trap
❑ Other (describe) ___.___ __.____.-_-._-_� _.__.___-_
4. effluent Tee filter present? [ es No If yes, was it cleaned? � yes' ❑ No
5. Observed condition of cc ilaonent pumped
0, SysrmP ped By:
(7av _..--_._. Mass 1AR95E ass 1AD31Z
_ .----
C`a Vehicle I.Jcense Number
Bateson Enterprises, Inc.
Company
7 I. :._-c ion where contents were disposed:
,LSD _.
Signature of Hauler Date
Signature of Receiving facility(or attach facility recce 1pt) Date
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