HomeMy WebLinkAboutSeptic Pumping Slip - 594 BOXFORD STREET 10/6/2006 }'
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0 Mi1 ,00061th assachusetts
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DER has p Y ppt � r �: ip roc d must
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,:.System, PU be submitted to thetlocaf�oaord of Health or otherda rc�vintha th r� erti phua t �epe
A. Facility Information
Important:
When lllinh®ut 1. System Location:
computer,use 6e),k_kyzz0V.—
only the tab key Address
to move your
cursor-do not CI /Town
Use the return City/Town _ State Zip Code
key.:. 2, ' System.Own Ier:
Z4 � m
Name
Address(if different from location')
City/Town State
Telephone Number
B. Pumping ecor
1. Date of Pumping ' 2, Quantity Pumped:
Gallons
"3. Type of system: ® Cesspool(s) ❑"'Septic Tank ❑ Tight Tank
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❑ Other(describe):
' 4, Effluent Tee Filter present? ❑ Yes E�""No If yes, was it cleaned? ® Yes ❑ No
5. Condition of System:'
6. 4Syem Pumped Sy: Vehiole license Number
a), Ai
aclarc �
Company
7... Location where contents were disposed: ,N ,/
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms,htm#inspect
t5forrrA.doc•06103 System Pumping Record.Page 1 of 1