HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 3 WINTERGREEN DRIVE 11/10/2025 Commonwealth Massachusetts
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System Pumping Record
Form
OEP has provided this form for use by local Boards ofHealth. 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 310CIVIR15.351.
A. Facility Information
Important:When ����/� �&�^�"
0Ungout forms 1. System Location: �'""' ��v /�W[D� ����"
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key. City/Town State zip
Cpde
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Name
Address(if different from location-)
City/Town State
617-866-5080 978-784-5842
B. Pumping Record
1. Date ofPumping 10/13/2025 2� (�uantUxPumpad� 1500
DateGallons
3. Type ofsystem: F-1 Cesspool(s) Z Septic Tank n Tight Tank n Grease Trap
El Other(describe):
4� Effluent Tee Filter present? Yes Z No |f yes, was itcleaned? Yes ZNn
5. Condition of System:
Good system tiproperly
6. System Pumped By:
Jason Elliott S71437 orV85257
Nwne- Vehicle License Number
|veater and Elliott Services LLC-D0AJason
Elliott Pumping
7. Location where contents were disposed:
GLSD
10/13/2025
%Si—,re of—Hauler Date
ignature of Receiving Facility Date
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