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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 240 FARNUM STREET 8/23/2021 Commonwealth of Massachusetts RECEIVED a� -- - City/Town of _moor-H-) AnAovcr System Pumping Record TowNaf t4°R�NpN�1F.R ` Form 4 �Ogp'RIMEN 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 LA rV-) key to move your Address cursor-do not IV Q V p O'13� _ use the return CR Town N 1 key. y State Zip Code 2. System Owner: m Name nan Address(if different from location) _ City/Town State Zip Code -7St - Telephone Number B. Pumping Record 1. Date of Pumping Date �L— 2. Quantity Pumped: I S©C) Gallons 3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): - --- ---- 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6. System Pumped By: Name Service Pumping&Drain Co.,Inc. Vehicle License Number 5 Hrtlberg Puic Company Norm E..+.a.Ina ulae% ,......p.a�Ufa. 7. Location where contents were disposed: G LS'n 113 ) ,:X� Signature o uler Date - Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1