HomeMy WebLinkAbout- Septic Pumping Slip - 165 CARLTON LANE 5/8/2019 I
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RECEIVED
�L\ Commonwealth, of Massachusetts
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�. System umping RecordT 14, ����� �� III���°�"�DOV `°�
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has provided this form for use by local Bloards,of'Health.Other formsa used but the
Information rnusl 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
approvingthe local Board of Healthauthority within days from the pumping date i
accordance with 3 - 15.3511..
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A. Facility Information
Important:
When filling out 1�. System L
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CityrromlSt t Zip
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Telephone Number
B. Pulffipll; Record
Date of Pumping
2
Date Gallons
I syst sspool(s) Septic Tank Tight Tank Grease Trap,
R Other " I
w Effluent Tee Filter present?w Yes No If Yes,was it cleaned? El Yes El No
5. Condition of System.
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6.
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System Pump d Byd-1
Nn 10 A.'I"A 'Vo'hide License Number
7. Location where contents were dig
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Signature olf ReceivingFacility Date
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t System Pimping Record f 1
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