HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 706 FOSTER STREET 7/29/2024 Commonwealth of Massachusetts
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System Pumping Record
IUL 2024
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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 CMR 15.351.
HOUSE: front back side rear left righ
A. Facility Information BUILDING: nt back side rear left rl t
Important:When DECK: under
filling out forms 1. System Locatipn:
on the computer, T`�'`� �Si`Q"
use only the tab
key to move your Addres
cursor-do not MA use the return Cil !Town
key. y State Zip Code
2. System Own
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C c%**k %(\e C�
\ Name
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Address (if different from location) --
MA
Clty/Town Slate Zip Code
Co JS- s-p S-_3�Y,7
Telephone Number
B. Pumping Record
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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? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E ass lAD3
Name Vehicle I.Icense Numbe
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
nGLS
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2
Signature of Hauler Date
Signature of Receiving Facility(orattach facility receipt) Date
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