HomeMy WebLinkAbout2 - septic tanks - Septic Pumping Slip - 479 LACY STREET 4/8/2024 Commonwealth of Massachusetts00
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System Pumping Record ppR o a ti024
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DEP has provided this form for use by k"Boards of Health.inforrrtatlon must be substantially the same as Other forms May local Board of Health to de that provided here. Y be used, but the
determine the form the Before using this form, check with your
the local Board of Health or other a Y use The System Pumping Record must be submitted to
accordance with 310 CMR 15.351.approving authority within 14 days fibm the pumping date in
A. Facility Information
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bout fame I. System Location:
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2• System -� °L� ZIP Code
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B. Pumping Record Te+e�h°ne Nu^nber
1. Date of Pumping
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3. Component: °aes 2. Quantity Pumped:
° Cessp°ol(s) �] Septic Tank'.. Garlons
❑ Other ❑ Tight Tank ID Trap
. (describe): .
A Effluent Tee Filter present? [] Yes ❑ No
5• Observed condition of component pumped: If yes, was it cleaned? ❑ Yes El No
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Canpany "�"umber
7. Location where contents were disposed:
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System Pumping Record-Page 1 of 1
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