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HomeMy WebLinkAboutSepticTank - Septic Pumping Slip - 767 JOHNSON STREET 8/26/2024 Commonwealth of Massachusetts ��d°SST City/Town of System Pumping Record 262p`�4 BUG Forr714 r*tit 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 a rear le right A. Facility Information BUILDING: front back side rear left right Important:When DECK: under fllling out forms 1. System Location. on the computer, \ �� use only the tab key to move your Address cursor-do notuse l 1 An�- W- MA ©ti key,the return Citylrown Slate ZIP Code 2. System Owner: l� Ct Name nhm Address (if different from location) MA Clty/Town State Zlp Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2� 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) �] Tank Tight Septic Tank ❑ / g ❑ Grease Trap ❑ Other (describe): ttt 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed cjoition of component pumped: AA> 6. System Pumped By: Dave Tiney M ss 1AA95E Mass 1AD31Z Name velQicle License Nu er Bateson Enterprises, Inc. Company 7. ��tjon where contents were disposed: 1 g[2 N Signature oT Hauler Date Signature of Receiving Facility(orattach facility receipt) Date t5form4.doc• 11/12 System Pumping Record •Page 1 of 1