HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 22 FULLER ROAD 6/1/2026 C;ornmonweaItr�) of Massachusetts To
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City/Town of r
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(REF' has provided this f�cyrrr7 for lase by local Boards of Health Other for Ms may be u � a0m �f
information must t)e substantially the yarn as Mat provided herE`!. Before using lhis form), check wlth•yr:>ur
local Board of Health to determine the form Itley usc.7. The System, Pumping Record must be subrnitted to
the local Board of Health or other approving r.-iutP'ority wilhin 14 days front the Primping date in
accordance with 310 CMR 'I S 351 _.
t a :!< riClc rrfrr lef rl�ht
A. Facility inforn ation BUIt.oINC O-rat ck siderei7 cfr r�
hnportant; whtan D E'CK: UndeI
use only Itr to System rlt Location
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(Piling out forms 4 y
rm lhn carnparte�r, ,
y , d-,key to rrtove;yo,rrr f1t1t1rn ati � --
cur ar -do rrol ✓
u a the return _._.,. __....._-�._1p M6\
fey. Shale Zip Code
2, System Owner'
IYC rr1H
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Fl,cJclrr)�,sg (If(Jifiercr'il born locali<yn)
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City(1"overt _ ._,. __.,..__.. .... .. . ._.-,_ `� �1p e al _. _._.
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- Telephone Nun",br=_r
B. Pumping Record
1, Date of Pumping ___.... (" _`u ._.___ ._.-- 7 C) Quantity pun-i e-d'Y fa _----- _.-_.
Gall ns
3 Component: j ) Tight Tarrk Greasy! Tr,,—)p
(_..) Other (describe) _
4. Effluent Tee Filter presooti' [ ] �r'�'s n If yes was It cleaned? ( _) Yes [.�� fVo
5. Observed condition of r orrlponent pumped
6, System Pooped Fay
Cave ?-Inr Mass 1AA95E Mass 1AD31I
tVa(Yte VehrlCir i ic,e^rr.o Nurrit7er
Bates �n erprlses.-_Inc.
laorffipany
7, Location wt')el-e contents were, dispose((
LSD . �.... ..�.
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SI uro of HquIrir a
Signalurf? of Rrce;vlrird F,tc',ilif� or aliacti racilih rocei -
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t5form4i.dor• 11/12 Systern Pumping f2ecord , p,
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