HomeMy WebLinkAboutSeptic Pumping Slip - 43 Candlestick Rd 9.29.2024 - Septic Pumping Slip - 43 CANDLESTICK ROAD 9/24/2024 lommonwealth of Ma,,-sachuset S
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System Pumping Record
1. Form 44
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 forrn, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the ]coal Board of Health or other aPploving authority within 14 days from -.he pumping date in
accordance with 3110" CMR I r 3r
HOUSE fr o n t(back aside rear left I Q-h
A. Facility Information BUILDING. front side rear le— right
Important:When DECK, under
filling out forms 1. System Loc2tion-
on!he computer,
iise on", its tab
Key to move YOW �o d r e s s
cu,r3oi -do not MA
use the return
kev lty/7rown State Zip Code
2. System Ovvf!E�r,
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Address (if different from location)
MA
ityffown state Zip Code
lelephone Number
B. Pumping Record
1. Date of Pumping Quantity Pumped'.�ale Gallons
component: Cesspocii(s) Septic Tank ❑ Tight Tank t Grease r a p
❑ Other (describe):
4, f_7ffluent Tee Filtel, present? 0' -es No I' yes, was it cleaned? Yes No
5. Observed condition of com.1ponent PumPed
6, System PUM'Dea By
Dave Tin M a s s 11 AA 9 5 FE_ 11411ass 'AD31.
Na,
am Vehicle License Numb
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r
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7. (:oZon where contents were disposed
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Sionatuie of Haut Dave ,
Signature of Receiving Facility tkor altach, fac Pty receipt," Date
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