HomeMy WebLinkAboutSeptic Pumping Slip - 1635 OSGOOD STREET 7/30/2018 WE r ;� ED
Commonwealth of Massachusetts ���� ��� �0 I�3
City/Town ofd
System in Record
Dorm 4
DEP has provided this form for use by local Boards of Health. Other farms 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 810 CMR 15.351.
A. Facility Information
Impgrtnt:VNten
fling out forms I. System Location:
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cursor y,o do noour Address
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Zip Cuda
2. System Owner:
Name
�tr' �, ' Addrasa pf d4�erent from lacatlon)
Clty/To" Slate
Tip cede
Telephone Number
Pumping ecord
1. Date of Pumping Date u�1 2• Quantity Pumped: '`
.��°�" Gallons
3. Component: [I Cesspool ,
Cesspool(s) M Septic Tank ❑ Tight Tank
g ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If es was it cleaned?
Yes, ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Name
Vehicle License Number
7. Location w ere co tents were disposed:
Signature�Hau
*—�64
Date
Signature of Receiving Facility(or attach facility mcelpt) Date
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