HomeMy WebLinkAbout- Septic Pumping Slip - 33 EAST PASTURE CIRCLE 6/20/2019 uommonwealth of Massachusetts,
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RECEIVED
Cifty/Town
System Pumping Record
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Form 4 OWN,OFU
ENT
DEP has provided this form for use by local 'Boards of Health. Other forms may be used, bust the
information must be substantially the same as that provided here.. Before using this form,, check with
your local Board of Health to determinethe fora they use., The System Pumping Record rust be
submitted itte to the local Board of Health or other approving authority within 14 days from the pumping
date in accordance with 310 CMR 15.35 A, Facility Information
Important: System Location*
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B, Pumping Record
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. Date of Pumping Dot 2. Quantity Pumped: Gallons
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3. Component,* Cass 1 s) Septic Tan 'Tight Tank Grease Trap
Other(describe)-.'
. Effluent Tee Filter present? Yes It yes, was it c1 ianed? Yes No
5, r °I condition of component plumped:
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t5for . 1 r1'2 System Pumping Record Fags 2,
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Commonwealth
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City/Town of'
WO System Pumping Record
A"
Form 4
EP has provided this form for use by local,1 Boards,of Health. Other forms may used,, but the
information must be,substantially the same as that provided bare. Before using,this form, check with
your localBoard Health to determine the form they use. The System PumpingRecord must e
submitted to the local rd of Health or other approving authority within 14 drays From the pumiping
date in accordance,with 310 CMR, 15.351.
6. System Pumped By.
Name— VeWe"cense Numb....
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cx - NJ
T. Location where contents were disposed-
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