HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 137 CHRISTIAN WAY 12/18/2025 Commonwealth of Massach�,isetts
= City/Town of
p System Pur-nping Record
Farm 4
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 Ihis form, check with your
local Board of Health to determine the feral lt1ey use -1 he System Pumping Record must be submitted to
the local Board of 1--lealth or other approving awhority within 14 days from the pumping date fn
accordance with 310 CMR 15351
—
_.__.. HOUSE front back side rear I�ft �ht
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A. Facility informatiori BUILDING: nt back side rear deft rif,ht
Important: WYac;n
DECK: t.tnder
018ng auk forms I. System t oCa 1`1
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State,, Zip code
2. Sy m Owner:
�\ Name
IPIIY(1,,,
Address (if different from location) —
MA
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E3. Pumping Record --
1 Date of Pumping .! .Cl ... - 2 (quantity Purnped.
C)afer Gailons
3 Component. Lj cesspool(s) FL tic �T�r�ni
p (.__] Tiyht Tank �� Gcease Trap
Other (descrlbee):
4. Effluent Tee Filter present? [_] Yes g' EJc7 If yes, was it cleaned? ❑ Yes �_) (�o
5. Observed condition of cornponc-t C purnpPc
6. S _, ....,.
y en-1 f- `p rra(a e ci By.
ave `f iney Mass 1AA95EE Mass IAD31Z
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Vc trl(.Ir. Ucense Nurrrt er
Ba so-n-Enterprises Inc
Cr�rtiy7�ny
T Location where qontents were disposed:
4ic rrtafme of f-i�aul�r
).+tr
Sigrialure of R<ac c.lvinc{1=raciiity (or aftrarh facility re,c;rsi{>t) Date,
i5form4.doc- '1'1t12 Systern Purn ing fkecorrj Page 1 of 1