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HomeMy WebLinkAboutSeptic Pumping Slip - 165 CARLTON LANE 5/30/2017 Commonwealth of rar wichu etts City/Town of System Pumping Record Form 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 this form,check with your Wal Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15,351. RECEIVED A. Facility Information e ",o ?017 ad tomw 1. System vocation: at the conVuw, 1 F t4 lw4 � use Only the tab PoRTMENT key to Addmes i r° use the room key. state Zip Code 2. Syat Owner. Norm- z AOOresb(ir dflrerent from IOWtIOri) Clty/Town State Zip Cade 5^ _J, Telephone Number . Pumping Record 1. Date of Pumping r: <> f ' i 2. Quantity Pum Gallons 3, Component: ❑ Cess �f Pools) ®peptic Tank 0 Tight Tank ❑ Grease Trap ❑ other(describe): 4. MOM Tee Filter p nt? ❑ Yes ❑ No If yes,was It cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: S. Sys Pum By: 4 ' Vehlde t.mse Nwnber m► gy ) . ... r• Location where contents were disposed: nature a Hater w- u 8ipnature o1 Recelvinq FactlNy(pr attach fadlltyr recelpt)Y _ ®ate ts%m'41.0100-11/12