HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 263 RALEIGH TAVERN LANE 4/29/2026 Commonwealth of Massachusetts M, r
Y� ity/Town of o oll n oVer
h System Pumping Record
Forr714 MAY 2026
DEP has provided this form for use by local Boards of Health. Other fprrf� „ us id, bul the
information must be substantially the sarne as ti� at provided here. Be;forc`uss q-H ' with your
IOC2I Beard of Health to determine the form they use. _I..L e System Pumping Record must be subrrritted to
the local Board of Health or other approving authority within 14 days from the pumping date In
accordance with 310 CMR 15.351
H0USC front back si e rea le ripl.t
A. Facility information BUDDING front side rear left fight
Important: When
C)F."CK: under
use
out forms 1. SySCen"1 I_oC On:
us llo only
hop aEr, /►� // ,r��(/, F�
e r>r�Iy(hrj lab _
key fo move yo.r.ir Addross
cursor-do nol ,tt MA
usethe return _ __._._ .- ---._..-.-._ _----__-. --.-_-- _ - __..._. (1-_._.. _ _ —__---_--_ _ ._
key, City(Towo stale Z.p Code
2. Systern Owner:
Ill -
$fit F, ...-.-_..-
Add(oss (if different frorn loca(km)
M Q
C.,Ity l o��an c tu(e,S64
„/j r�Codr
" .
Trlepi�cnne t�ur�7ber
F.3, Pumping Record
1. Date of Pumping ___-- --.__ _____.._._- 2 Quantity Purrrped
71e Gallons
3 Component Cesspool(,) U-See;ptic Tank Tight Tank� 11 Grease Trap
j Other (describe) _..-._. _ _. _._-____ ____._ --_.____ --.____--_.-------------
._____..
4. lfluent Tee Fi(ter present? o If yes, was it cleaned? [ 1'E;s (_ ) No
5. Onserved condition of component rn ed'
6. System Pu `ped By
DaV Tina, Mass 1AA95E M s 1AD317
arnc= _..___.
vcY7lc;lo L.�CensPi' Nurntie;r
t 'scn[::nlerprises, Inc
Location where Contents we -,, disposerJ
'§LSD
Siy ns.�lurrs nt h�l
� 0ale _.__
_.....__...---..—....--- —---siynalrrre of r2ec.eswli�g F �cllity (or rrftac.Pr fr�rilily rcceipl) O7(0 ��� —
�form4.dCC 11I11 systern Pumping PecorC'1 PactC; '1 of 1