The URL can be used to link to this page

Home My WebLink AboutSeptic Tank - Septic Pumping Slip - 65 BROOKVIEW DRIVE 4/8/2024 0 end°vac Commonwealth of.Massachusetts City/Town of System Pumping Record --�qxent DEP has provided this form for use by local Boards of Health. �1e information must be substantially the same as that Other fOrMs rWY be u local Board of Health to determine the form the u provided here. used, but the the local Board of Health or t r• The System Pumpin slug this form, check with your accordance with 310 CMR 15.351.approving authority within 14 days from thRecord i Must sage isubmitted to A. Facility Information 11"ortaft When bout forms 1. System Location: aueor-do not Addy... Lae the return c C ' key. GttY/T owr� o2. System Owner. state Nine • Awdre8a ntdt' *,,,,,locatim) WIDwn Zip Gode B. Pumping Record TelB�10"e Nwnbe 1• Date of pumping Ir3o IaN 3. Component °Me 2. Quantity Pumped: 1 ❑ Cie$$pool(s) eptic ralbns © Tank ❑ right Tank ❑ other'(describe): ❑ Grease Trap 4. Effluent Tee Filter present? 0 Yes ❑ No 5• observed condition of component pumped: If yes, was it cleaned? ❑ Yes ❑ No 6• System Pumped By: C � a N mr Root ( � Vehk�e Uoense Number any 7. Location where contents were disposed: Sign of Mauler Date �DnattNe Of IZecg��n„yb„�w1 ^""^� facoy^ems) I Date ,doc•11/12 S"lem Pu i mP ng Record•Page 1 of 1 �. ` .. .. S e� -- --F-------,_ ---. _ - .. . �. ___ _: <.�.; 4: � .. .. ' +..