HomeMy WebLinkAbout- Septic Pumping Slip - 200 CANDLESTICK ROAD 10/16/2018 Ophimonwealt of Massachusetts
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System.Pumping Record!
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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 yo
local Board of Health to determine the form they use.The System Pumping Record must be submitted
the local Board of Health or other approving authority within 14 days from the pumping date In
accordance with 310 CMR 15.361.
A. Facility Infonnation
OW ftmw 'I System Location:
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zip Code
2. System Owner:
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�'M/4Anlea Of(ilerem imm im4wil�
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0lAlrl State zip Code
Telephone Number. : .: 0. Pumping Recorel
1. Date of Pumping /A P
Date 2. Quantity Pumped: zV
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3: Component: ® Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned?
❑ Yes No
5. Observed condition of component� Pumped:ped:
Q. System Pumped By:
Name
Vehicle Ucense Number
Company �' --------•._. �
7. Location wh re contents were disposed:
41
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Date
8ianalure of Recelvinp Fac,7, (or altach facloly receipt) Date