HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 28 JERAD PLACE 8/16/2022 Commonwealth f Massachusetts ff 8��*��^D�������'��k
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System Pumping�� Record
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OEP 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 hero, Before using this hznn, check with your
|ooe| Board of Health to determine the form they use. The System Pumping Record must be submitted to
the |oou| Board of Health or other approving authority within 14 days from the pumping deba in
accordance with 310CW1R 15351
HOUSE: C:[ro—
:n:t:Dack side rear left CEO
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
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use only the tab
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key. City/Town— — State � Z~ ``~`
2. System O
Address(if different from location)
CityfTown State Zip Code
-felepho�e Number
B. Pumping Record
-7 2 �
1 Date ofPumping bh/ Pumped: Q
3. Component �� Cesspool(s) :' SepdcTanh E] Tight Tank [] Grease Trap
Fl Other (describe):
4. Effluent Tee Filter present? [] Yes ZNo If yes, was it cleaned? E] Yes [] No
5. Observed condition f componentpumped:
0. System Pumped By:
Dave Tiney Masu1A\Q5E
Name Vehicle License Number
Bateson Enterprises Inc__
whereCompany
di d
CGLS
-��jgnature—of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5mm4.00c' 11/12 System Pumping Record 'Page 1o, 1