HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 353 BOXFORD STREET 7/1/2024 Commonwealth of Massachus tts
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City/Town of ��p� °
o System Pumping Record �° �p1tio
Form 4
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DEP has provided this form for use by local Boards of Health. Other forms may str but the
information must be substantially the same as that provided here. Before g t is form, check with your
local Board of Health to determine the form they use. The System PumArRecord 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.
HOUSE: front ack side rear left igh
A. Facility Information BUILDING: front back side rear left right
Important:When
DECK: under
filling out forms 1. System Location:
on the computer, ��
use only the tab CS
key to move your Address Q
cursor•do not ! t �jv
use the return Cil (town MA
key. y Stale Zip Code
2. System Owner:
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Name
num
Address (if different from location)
MA
city/Town State 1 Zip Code
Q
qq ,%
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Daatete 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:
Dave Tiney Mas 1AA95E Mass 1AD31Z
Name Vehicl Ucense Nu ber
Bateson Enterprises, Inc.
Company
7. ation where contents were disposed:
OGLS
Signature o;Hauler Date
Signature of Receiving Facility(orrattach facility receipt) Date
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