HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 808 JOHNSON STREET 10/28/2019 X Commonwealth o f Massachusetts ACT 2 �®
City/Town of-.. fh And �l r rowN o� V 201,9
Syst4em Pumping Record H�cryoFpry�Noo
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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.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab [)
key to move your Address
cursor- h not I >A �a ye'K
use the return M-�
key. cityrrown State
Zip Code
m
2. System Owner:
D ' rl
Name
F.—M
Address(if different from location)
City/Town
State �� 3�� Zip ode
Telephone Numbs `4 `,B. Pumping Record �� )
1. Date of Pumping Date / -- 2, Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) rA Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes,was it cleaned? Eg-Yes ❑ No
5. Observed condition of component pumped:
-rGir
6. System Pumped
rBy:v:a��
�
Name � ��
Service Pumping di:Drain C o in, Vehicle License N:
Company North &hfAOl8ba
7. Location where c6-nr-A—&i—d*8s'ed:
10
Sigrfature of Hauler Date 11 -►-
Signature of Receiving Facility(or attach facility receipt) Date
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