HomeMy WebLinkAbout- Septic Pumping Slip - 2198 TURNPIKE STREET 10/15/2018 Commonwealth of Massachusetts Cty/Tawn Of_jL , p System Pumping Record Farm 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 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 16.361. A. Facility Information 1m t:When '-,Oft out forms 1, . Syste Location: on the compto t ae to va tab add s:do not Nsy, CItyrromi Slate Cade 2. Syste Ownerp Name 1 r; Address pf different from location) ty em Cl /T Slate zlrl-Code ' Telephone Number B. Pumping Record 1. Date of Pumping --'2k I 2, quantity Pumped: Hale Gallons 3: Component: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank g ® Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was It cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6. System Pumped By: Name Vehicle License Number Cop ainy 7. Location where contents were disposed: S _.. /./ Signature at Hau Date Signature of RecelWng Facility(or attach facility recaipt) Date rsft,na d^0%4 4/40