HomeMy WebLinkAbout- Septic Pumping Slip - 2198 TURNPIKE STREET 10/15/2018 Commonwealth of Massachusetts
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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
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2. Syste Ownerp
Name
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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
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