HomeMy WebLinkAboutSeptic Pumping Slip - 70 Oakes Drive - Septic Pumping Slip - 70 OAKES DRIVE 10/8/2024 1
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ommonwealth of Massachusetts
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System Pumping�Record
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bl✓P has provided this form for use by local Roards 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
Ipcal 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 16,351„
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A. Facility Information Of
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Important.When ; 17d0VLgr
filling out forms I System Location:
on the computer, `� 0 01`(QS )0 Y l VT' DEC
use only the tab Q
key to move your Address
use or rdo not K, ., N , Y�Y�C�UV��` � fealt
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key. Wrown state
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2.i System Owner: � ant
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Name
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j Address V different from locaton)
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City/Town state zip Code
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Telephone Number
eh Pumping Record I
1. I bate of Pumping Date 2 Quantify Pumped; SUC)
Gallons
S. Component, (l Cesspool(s) Septic Tank [] Tight Tank [3 Grease Trap !
b Other(describe),
E
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4. Effluent Tee Filter present? G] Yes ] No if yes,was it cleaned? E-1 Yes [ No
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6, Observed condition of component pumped: !
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6. ;Systems Pumped By:
Name Vehicle License Number
Wayne's Drains, (no.
Company
7. ILocation where contents were disposed:
!Signature of Hauler Date 1
i
signature of Receiving Facility(or attach facility recalpt) pate
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