HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 76 OLYMPIC LANE 10/5/2020 onwealth of
Massachusetts
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System PUMPIng Recorcl OCT
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DEP has provided this f r H�0"ORTHAN00'VER
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se Y local Boards of Health. Other forms
local Board of Health to determine the form they usehat r The S st re. Before using th a fa used,May be but the
the local Board of Health et other che for
approving authority, System Pumping Recartl must be scic with your
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f 2• System Owner. State — ----
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Name �A a C rn
Address(ifdt*rentfrom location)
CitYrl'own
State UJ�
Telephone Nu�bBr 43�1
8- Pulp PIng Record
�- Date of pumping
Date 2. Quantity Pumped; C1�
3. Type of system: (_] cesspool(S) Septic Tank Gallons
❑
❑ Other(describe}: Tight Tank
4. Effluent Tee Filter resent?p ❑ Yes ❑ No if yes, was it cleaned?
• 5- Condition of System: ❑ Yes ❑ No
6. System Pumped By;
Name
Corn---py 1 rC�C Ze ICS r C Vehlcie Ucense Number
7. Location where contents were disposed:
• Ls �
Signature of Hn, er
Date
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System Pumping Record Page 1 of I
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