HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 295 WEBSTER WOODS 4/22/2024 Commonwealth of Massachusetts J�`l ��dovet
City/Town of
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m System Pumping Record eR 2 ti ti024
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Form 4
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 C M R 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab --
key to move your Address _
cursor-do not Alo r44-� A nL-J u yer
use the return rCitylfown State Zip Code
key.
2. System Owner:
L%2 IC txs r z
Name
nmm
Address(if different from location)
City/Town state Zip Code
q7 -y� - ��ti�i
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: 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? In/yes ❑ No
5. Observed cgndition of component pumped:
�OC�
6. System Pumped By: i • 1
Name Vehicle License Number
-IAM414 A. .c-x d ; �n P(wvYbN ; 1 1141
Company
7. Location wher ntents were disposed:
Signature of a er Date
Signature o Facility(or attach facility receipt) Date
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