HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 339 ABBOTT STREET 11/12/2025 Commonwealth of Massachusetts
Town � over
c ' -Y City/Town of
V 14 2025
System Pumping Record
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DEP has provided this form for use by local Boards of Health. Other forms may be used, b
information must be substantially the same as that provided here. Before using this form, check with your
focal 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 310 CMR 15.351
HOUSE: rant back side rear !.eV rig lit,
A. Facility Information BUILDING: front back side rear left right
Important: When DECK: under
filling out forms 1. SyStef Iat O �
on the computer,coputer,
use only the tab 9-
.__.__—l— ____------
key to move ynur Ac Chess
cursor-do notMA
use the return
key. C4tyf1 r�wn state Zip Code
- ?_. Sys ernOwner: G
0f 16 _..
__ -----------
"((yyC..._._ _...._.....
Address(if different from location)
M A,
Giry(7own
Tel„ahane plumber
B. Pumping Record
1. Date of Pumping _.___ _.._-_..---------
Data 2. Quantity Pumped:
Ga Ions
3, Component: ❑ Cesspool(s) V— Septic Tank [_] Tight Tank ❑ Grease Trap
❑ Other (describe): -
4. Effluent Tee Filter present? F] Yes Na If yes, was it cleaned? (❑ Yes ❑ (!o
5. Observed condition of component pure ped:
5. �!�ve
tern umped By:
T1 1eY..._....- Mass 1F 95E Ma s�1,A��D3
_ ._.._._-- __.._.._ _.. __ ____--__`—
arrie Vehfrle License Number
ateson Enterprises, Inc.
any
7 Location where contents were disposed:
G SD
._ -- __.--- `.I
Sign ire of Hauler Date __..._ ._..
---- ._
signature of Reaeiving haaliry(or attach facility receipt) Date
t5form4.doc• 11/12
System Pumping Record •Pale 1 of 1