HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 139 VEST WAY 12/22/2025 4 � Commonwealth of Massachusetts
City/Town of
Pumping stern SRecord
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DEP has provided this form for use by local Boards of Health, Other forms may be used, but the
information rnust be substantially the sarne as lhat provided here, Before using [his form, check with your
local Boaf d of Health to determine the forrn They use The Systern Pumping 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 CMR 15,351,
_._.__---.____ . NCJUSE front back side rear left rig
-A. Facility lnformatlot1 8UuLDING: font back side rear left ri€3
Important:When
DFCK: Lander
on the compuler, rl� Location",
tElsle g out
orilyllfQs asb y
Key to move your I dorf 5
7.1{7 Code
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use, [he reluen _.
key C,I I l r'civ,�n
2 S y s t' rt Owner. , J
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Address (II different born location)
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Telephone Number
B, Purnping Record
1. Date of Purnping _._. _._-- _.._ 2. Quantity F)urd _ . _ __-.......___...
Dale npe Gallons
:3. Component. C ess-sool(s) Septic."l"ank C,� Tight Tank ❑ Grease Trap
l� Other (describe) --- _----_ ------------_.___.
4. Effluent Tee f-ilter pr(-,sent? [ ) Yes _ No If yes, was it cleaned? ❑ Yes � No
5. 0bservecd conr'ditic)n of cornponeril purnped
6 System F-Iu(npe� d By
Dave l inf Y Mrass '1A,A95E Mass 1AD3'1Z
Names Vehicle License Number
Baa eson EntorprisPs, Inc.
Company
7 Location wherc= contents were disposed.
Cat_a()
------- __._.- _.
Signatory# cat Hauler t .r
-- __
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`ilge7 alurer or F�r!eeivinc� Fraeilely (car alir3c:1� f,;�cility rr�e;ei[.�l} Dale
5lorrr74.dUc 11112 Sysiern Pumping Record - Page 1 ni 1