HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 289 STILES STREET 5/8/2020 Commonwealth of Massachusetts husetts D
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Fo MPIng Record MAY S
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DEP has provided this form for use by local Boards of Health. Other orms may be use
information must be substantially the same as that provided here. Before using this for
local Board of Health to determine the form they use. The System Pumping Record d' be the
the local Board of Health or other approving m, checlt with your
pp g authority. d must be submitted to
A. facility 1nf®a-mat!®n
important:
When filling out 1- System Location:
forms on the
computer,use /I
.only the tab key Address
to move Vour
cursor-do not
use the return Clty/Town ✓ems G
key. State
2• System Owner: ZIp Code
t Name
Address(If different from location)
City/Town
State
7 C_ Zip Code
Telephone Number 3
B. i' ping �a'eCor
1. Date of Pumping 3- 13
Date 2. quantity Pumped:
3. Type of system: � � Gallons
❑ Other(describe):
❑ Cesspool(s) Ly'Septic Tank
❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes ❑ No
If yes, was it cleaned? Yes El No
5. Condition of System: ti
6. System Pumped By:
Name
L2 MCA C Ze JC Vehicle License Number
—om—pa—ny�.f.1 S S C-'��t C
7. Location where contents were disposed:
,- LSD
Signature of Hauler
Date
t5form4.doc>06/03
System Pumping Record•Page 1 of 1