HomeMy WebLinkAbout- Septic Pumping Slip - 2163 TURNPIKE STREET 4/1/2019 Commonwealth of Massachusetts
r y Gity/Town of
_ System urnping Recordx
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. J
A. Facility Information
Important:When
filling out forms 1 System Location:
on the computer, J /
use only the tab 5 �(/r J a21 r �� 7
key to move your Address
cursor-do not f/
use the return 'A0 ' lIn , o Z'y 0kl-
key. awrown State Zip Code
!� 2. System Owner:
Name
Address(if different from location)
CityFrown State „_ Zip code
. 7_
Telephone Number C>
B. Pumping Record
1. Date of Pumping Date Gallons2. Quantity Pumped: �!'
3, Component: ❑ Cesspool(s) ptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? -'fie No If yes,was it cleaned? es ❑ No
a. Observed condition of component pumped:
-00J
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date t
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