HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 67 RALEIGH TAVERN LANE 12/19/2025 LL\ Commonwealth of Massachusetts
c City/Town of
System Pumping Record
Farm 4
DEP h�1s provided this form for use t)y local Boards of Health. Other forms may be used, but the
Information must be substantially the sarne as that providers here, Before using this form, Check with your
local Board of Health to determine the fom-i they use. -The System Pumping Record must be submitted to
the local Board of Health or other approving autlhority within 11.1 days from the pumping date In
accordance with 310 CMR 15,351 -------- ----.
_ HOUSE: front back sld as-1
Pft right
A. Facility Information BUILDING: front back side rear left, ,ht
Important;when DECK: under
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B. Pumping Record
1 Date of Pumping _..� -__._- 2. Quantity Pumped -- --- - -
rate Gallons
3. Component: [] Cesspool(s) 'eptic Tank ❑ Tight Tank,� ❑ Grease l'rap
Other (describe): -— ------------- ---- -- -- - — _--------_-- - ._ - -
4. Effluent Tee filter present? _ Y No If yes, was it cleaned? Yes �_) No
5. Observed condition of cornpone t pum)ed
6. SG'son
ped By
D ._ Mass '1AA95E fviass1AD31Z
N Vehicle License Nor fiber _--------.____
Berprises Inc. _..._
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7. C000n ,t ere nten e diiss-posed:
Signature of Hauler Date
Signature of Receiving Facility (or attach facility receipt) Dame
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