HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 213 CARLTON LANE 2/16/2026 i
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Commonwealth of Massachusetts
._.; City/Town of
S stem Purat i i y nc� Pecorc
F o r rri 4
DEP has provided this forrn for use, by local Brvafds of Health, Other forms may be used, but the
in orrnration i'nus; be sut.)stantialiy the, same as that provided here, Before Using fhis form, check with your
local Board of l-dealIh to determine the forrn they use. 'The System Pumping Record rnust be subrnit ed to
the local Board of Health or other approving rauthori('y within '14 days fron) 'he purnging elate in
accordance with 310 CWR 1 r} 351 __. __ ____ _.._
_._ .. ._... _,..._ _ ... ._ HOUtE frot7Y back
stc1� rear r�ft i
A. Facility Inforr-nation au �o o side rear e r'
Important:Whorr
(>ECK: undeI,
I filling out forms 1 Syster—n Locatlon:
on the computer,
use ordy tho lab _-..
1 key to move your Ad rasr
1 cu+'sor ,do r17t MA
use the relurrt __._.___ _ � - _.. _--...____ _____.._._ ._.._. _ _...._._ __.._
key cityrrown Stit Zlr Cpc1p
?. Systeltl Owner:
-rrnrri 'r�
Address (if different from location) _
MA
-_..__ _ __.. -.._._ _.._. .__..... -----_-... -..
CIIy('rown Sl�lpw Zit?Code
�.
Te It phone Number
B, Pumping Record
_,.. �.
1 Date of r�Iurnpinc — —..
r�.,te Quantity F un7ped.
c"aallprts
3. Cor-npone,nt (_-) Cesspool(s) ] ptic Tank ❑ -right Tank g ❑ Grease Trap
(_} Other (describe): _..____ _--__-- - __.--
N
i - r � f�lo If yes, was it cleaned?, Yes ❑ f7a
4, E-ffiluent Tee Filter �rpser7l'.
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f� 5 ObservedorObserved condition o( e orr� 7ar7e nt p twnned:
a
F Sy errt f trnpec:f E3y
R , r
U ve T Mass IAA95E Me, s 1AD3
ai7�rt Vehicle Llcpnse Nurnbpt
( niFrnr,�.�n �rl�ns�s, Inc.
( 7_ I ' alion vvt 're rGlonte( is were di",��
r
CL5D/ _.
7tyrtslure� <�I Hate _..
,
- Dale
f
� loion,,7lurr„ of E-tecc.tviny Facility (or rllnrtt fnr.,ilily (<t,6ral) Dale _._.
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i 15ft7rrn4 C10c 11fiZ Systerr7 Pf-WIVing Record , Page 1 of t
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