HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 185 BRIDGES LANE 12/27/2025 Commonwealth of MaSS2chUsetts
City/Town of
a = - System Pumping Record
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DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
Vocal 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 fron ide rear riphT
A. Facility Information BUILDING: ront back side rear left right
Irnpor-tant: When DECK: under
(Wing out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do nol /y-�n C MA
use the return — -- ——-----..-------—. --------------� _�---- —--
key, City(1'own State Zip Code
2. System Owner.-
Address (if different from location)
MA
City(7own State Zip Code
Telephone Number
B. Pumping Record - ___ — �--------____--
1. Date of Pumping --- z� - — 2. Quantity Pumped:
-bale Gallons
3. Component: [] Cesspool(s) Septic Tank ❑ Tight Tank
g ❑ Grease 1-rap
❑ Other (describe) __------._-- ----------------__--------___.____ __.�______--___ ___—._--
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component umped:
6. System Pumped By:
Dave T I n e� ---- -- ------------ ---_ _s 1 AA9 5 E� Mass 1 A D 31Z_
Name Vehicle l_iranse ber —_ --- --- — —
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed.
LS
Sign of Hauler Date
Signature of Receiving Facility (or attach facility r e c e i t) Date --- -- ---
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