HomeMy WebLinkAboutSeptic Pumping Slip - 165 CARLTON LANE 7/30/2018 EIVED
Commonwealth of Massachusetts EC
Ci,tyfTown of JLA, 302016
System Pumping Record ORT[A ANDOVER
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
local 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.
A. Facility Information
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forms 1, System Location:
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2 System Owner:
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Name
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' �fi��'"'`_ Addne�s(ff different from location)
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,Zip Cade
Telephone Number
Pumping cord
1. Date of Pumping data . Quantity Pumped: -�- �
Gallons
3. Component: ❑ Cesspool(s) 19 Septic Tank ❑ Tight Tank
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❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes [l No
5. Observed condition of component pumped:
6. System Pumped By:
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. vehicEe i.lcense Number
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7. Location when jcontents were disposed:
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SignatureHu
Date
Signature of Receiving Facility(or attach faculty MOO)— Date
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