HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 196 SUMMER STREET 1/28/2026 T own
f�()rth lAfIdOVer
C;omn� onwealth of Massachusetts 4dr'S
F r� City/7 ow gr��pyn of 2 8 2026
System Pumping Record
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DE P has provided this forrrrt for use by loci{ Boards of Health. Other forms may be used, but the
information must be substantially the, sarne as that provided here, Before using [his form, check with your
local Board of Health to determine they forn-1 they use. The System Purnping Record must be submitted to
the local Board of Health or other approving authority within '14 days from the pur-nping date In
accordance with 310 CMR 15.351 ___ _.-----_ -____-
. ._ ... ---_--- H0USL: (front",back side rear" In t'pri ht
A. Facility Information BUILDING. front, back sidle, rear --rETi rif,nt
Important: When DECK: UnC.1el'
ffiHnp out forms 1. Syster�] oatIon—
on the cor'nputear, r
use only tho tad
key to move your �dC1f 9S
cursrur-do nolAil-use the return 9 '..__-.._. _ _- Mfa ....._ _ ..` _.._-.._.__ ..
t r: Ctyffown i?,t�ate" Zip Code y.
2.
�.._ y a' rT1 OWr f'I':
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Address (if different f(arn ocation) _
MA
_ ip Code,
91'ione Turner
B. PIarnping Record
1. Date of Pumping ..___---- 2 'Quantity P imbed
n`alra Gallons
3. Component: [� Cesspool(s) (_ Se tic 'Tank( [_ Tight Tank ❑ Grease Trap
( ] Other (describe)
,
4, Effluent T pee Pilfer resent? P Y >, [ No If yes, was it cleaned? J2 Yes L^ No
5. Observed condition of corn-)anent E?,v nl)e cJ
r
6 X/Systcem Pwn1�ed By
7wvr' T lneaY.._- Mass 1AA95ES Mass 1AD31Z
— --iJarnrn \Ir,hlr,le License Nuvcalacr
Rateson Enterprises Inc_ _
C 7 Tarry
7. ccak on whetre contents,re dispel
GLSD
Su ratalure of Hauler
J Dra1i.
SIclnalurF, of Re;.c:civing Facilit-y (or aCtacYr (axCilily rercr,ipO Crate
t5form4.doc- 1)112 Sy tetra r'umpirrg Record I),- r; 'I trf'1