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HomeMy WebLinkAboutSeptic Pumping Slip - 57 Candlestick Rd - Septic Pumping Slip - 57 CANDLESTICK ROAD 9/26/2024 commonwealth of Massachusetts City/Town of System Pumping Record 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 submltted to the local Board of Health or other approving authority within 14 days from -.he pumping date in accordance with 310 CMR 15.351, HOUSE: front back side r ar eft' fight A. Facility information BUILDING: front back side rear right lmportant:when DECK: under � filling out forms 1. System Wcation: on Ilse computer, "� r 1 `� krse only the lab __ i , �PS}tC t key to move your Address cursor •do not tO t1 � MA C, use the reltfrn — -- -- 1 key, CIIy/Town Stale Zip Code 2. Sy tern Owner: 1 Name arwn Address (If differonl from focal%on) MA Siat© Zlp Coda _ Telephone Numbaf mm— B, Pumping Record 1. Date of Pumping oat--e - Y� — 2• Quantify Pumped: Gallons 3. Component: . ❑ Cesspooi(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filler present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5, Observed conditicin of component pumped; �p(Me, 6. System Pr<fn3pE�d By: Dave Tined Mass 1 AA95E Mass 1 AD31 Name Vehicle Llgense N Pet Bateson En(erprises, loc. Company u 7, �a 'on where contents were disposed: GL5L) Signature of flouter Dale �� Signature of Deceiving Facility(or attach lacillly receipt} (date 151orm4.d6C 11(12 System Pumping Record-Pale 1 of I