HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 197 VEST WAY 11/14/2025 Commonwealth of Massachusetts TO
c City/Town of
System Pumping Record
Y .� NOVO2
F o r ri-1 4
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DEP has provided this form for use by local Boards of Heakh, U s I' be used, but the
information n7��fst he substanCi" y y all the same as that provided here. Before usl � 1 ck with our
local Board of Health to determine the form they use. The Systern Purnping Record rntrs � submitted to
the local Boarct of Health or other approving authority wilhin 1 et days fronn 'he purnping date in
accordance with 3 10 CMF; 15,35,3` 1
1- USE. f ro-r7,��eck side rear heft rit>
ack side rear
A. Facility Information BUILDING. front b g
DECK: under
important:Whon
filling out forms } System Location
on the cornpular,
use only ins lab
krsy to move yoof Address
c„rsor . do not fnA
use li'le rf"Win _ __ G/- , _ __. — -- _..... .. _....
key r{tyf"t own r... stale Zip Code
l 7y term Owner
� 1
Arkrlross (it differoW Irr,ln incaHon)
MA
T .. 1 _. _.
C,IIy/-fown Sale 71� de
telephone C urr7t er
B. Pumping Record
�. -- - _......_.___._.
1. Date of f�t,arrlf��ing Dale, Quantity E'urr t ec�i G,-dlons
3. Cot-nponent. ( } Cesspool(s) (_ Septir ienk [�] light Tank ( ) Grease TrF
(_] Other (describe)
4, Effluent fee Finer present? ( ] Yes [k'`tJo f yes, was it c,feaneci7 Yes ( No
5. Gbser`ve(,.l condition of cr,>rr7l�onenl 17 �rlpfac:!:
6 System ucnped By �
D vca TInr>y Mass 1,�AJ3� ss TAC73'11
_ _... _
�JryYiu,lr I..IGenSc fVr.irt'rhr �, _ -- _
srtn f..fllf�rl7flses Iftc,
C"o m p-a n y
7- I._ ;anon c ntents wefe disposed
L 5,f1 s
Signalure of Hauler Dale
Signature, a(hke;ccivlrsy Facility(or <3tt<rc17 fr+crhly necoipt)
l5lorrn4.doc, 1'1112 System('runnping RecorcJ page, 1 011