HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 110 CRICKET LANE 7/8/2019 Massachusetts
l RECEIVED
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System Pumping Record
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P has provided this form for use by local Boards of Health. Other f6rms may used but the
information must e substantially the same as that provided here. Before using this,form,, check with your
Kcal Board of Health to determine the fora,they use.The System Vamping Record must be submitted t
the local Board of Health or other approving authoritywithin 14,days from the pumping date i
accordance with 310 CMR 15.351.
A. Facility Information
Important;When
filling,out forms 1 SystemLocation:
4-
use only the tad ..
keyi to move your Address
cursoriiiiiii not
use the return
1 , City/Town state Zip Cody
2. System
Name
I
Address if different from location)
City/Taws State Zip Cody
3
Telephone Number
B., Pumping Record
sui
Date Date i a Pumped: j
lons
1
3. Component., Cesspool(s) SepTank El Tight Tank 0 Grease Trap
tr(describe):
1
4.
Effluent Tee Filter resent? Yes its wasit,cleaned? s No
5. Observed condition of component
6. System limped y
Name Vehicle License Number
Company
. Location where contents were disposed:
Signature of Hetfiler Data
Signature of Receiving Facility r attach facilityreceipt) Datek ,r
t5 ,1112 System Pumping ii Record;ei Page
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