HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 100 RALEIGH TAVERN LANE 12/11/2025 . -I I,,luuver
DEC 1
Commonwealth of Massachusetts
City/Town of _ "�':`
,° System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, W the
information must be substantially the same as that provided h-ere. Before using Ihis form, check with your
local Board of Health to determine thy; form They use. The System, Pur�nping Record must be submitted to
the local Board of Health or other approving authority within 14 days from .he purnping date in
accordance with 310 (,MR 15.351
HOUSE front ack stile rear left rlf;hi
- ---_....
A. Facility information BUILDING conk back side rear left right
important:When
DECK: under
Mling out forms 1. Systerin Location: -�
on the computer, ///yy ,C
use Dilly the tab tt V i CMG G-� - -------- -- - ....._. _-------
key to inove your Aduress
c:urso� - do not �� t\/IA
use the return _..__
kry cliyrrown State Zip Code
2, System Owner:
arme
L�'
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Address (if difteronl from location)
MA
CIly( crwra ul, Lip Co ---
Telephone Number
_ _ _ ._-____.___
B. Pumping, Record
1. Date of Burn{ping - -- 2 -Quantity Pumped: � _......--- _..
Date Gallons
3. Cornponent [�_� Cesspool(s) [ J Septic Tank ❑ Tight Tank ❑ Grease Trap
Other (describe):
4. Effluent Tee Filter present? ❑ Yes ..__ No P yes, was it cleaned? Yes Q No
5 Observed condition of c mpone -)urnpe�rj
. ystent Pun)yped By
avt i inP Mass tF� rl�(y _ass 1AD,
_.....
anae> ✓ Vehicle License N mber
B, eSon EnteC. S nC,.
7 t oe;a ion w rere c>nter dispoud.
t LSD
Signature of Hauler Date
Slgn`ature of Receiving F�cility(or rat ach facility (eceipt) (late
l5lom14.doc- 11112 System Pumping Recorcl - f'age 1 of 1