HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 190 BRIDGES LANE 12/5/2025 f' M
Con-in,]onwealth of Massachusetts �v �
Ity/TC)wn of
System t�;I�r� Pumping Record
DEC
Y
r..� Depart,
DEP has provided this form for Use by local Boards of Health. Other forms may b ,ut the
information rnust be substanlially the same as lha provided harp;. Refore using This forrn, check with your
local board of Health to deterr-nioe the farm they use. The Systerrl Pumping Record must be subm�Med to
the local Board of Health or other approving authority within 14 days frorn -,he pumping date in
accordance with 310 CfVR 15.351 ___---
HOUSC: fron pack')ide rer lr ft�G ES
A. Facility Information BUILDING: fro n h � side rear left rig
Important: Whoo (BECK: under
filling oul torn-is 1 System t_oC tkE3
orr the Computsr,
kart/onlyto the tab yow Aricirei,s f�
r WrhOr -do nra( MA
uso the return
kc,y CIIyfl'own Sl,ln lip code
J Syqn wr7er
�;U r
kwd'. Narne
Add(ass (If dlffercwl frorn localkan)
MA
Cfl lfrrwn >lale lip Codr
y
1'el phU NurnY�er
------- ....._.__._.. ._. __ ..-_--__.__..___.._
g, Purnping Record
Date of f'a rr 7 p n g 2 Quantity €�u m p e d _---------
Cale Gallons
3, Cvr rpor)ent. (._] Cesspool(s) [ tic ..rank ❑ Tight Tank F ] Grease Trap
..] C. -i e r (describe) _ ____..._ ............... .
e1 Effluent Tee Filter present? ( _J 1' �_.) No It yes, was it cleaned? (] Yes ❑ No
5 Observed condition of component pornped
G �.. slefr.l l,uf_ )t-.C1 BYLDavr Tiney Mass 1AA`35E:: Mass �IAD31Z
on Fnte2rlmn p, Inc.
C;tzlar(7any
7 Loca(ion where, c Rents ere dis>pose�.�W.-���
G 5 C1
Slynature of f iaulef Date
Signsrturu 11 ry e,r nllocY�i Inclhty reenipt) at
15torm4.0c, 11112 Sysiern Pumping Record p@ge 1 f)(1