HomeMy WebLinkAboutSeptic Pumping Slip - 190 Farnum St - 01.08.2025 - Septic Pumping Slip - 190 FARNUM STREET 1/8/2025 �m� ~� &��� ��
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[[]��[�[]n��B��Hh of Massachusetts
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System ������%�^MC� ��e����yd ~'^` � � �"�°
Form 4
Health Nparfment
DEP has provided this form for use by local Boards of Health, Other forms may be used, but the
information must be substantially the name ae that provided here. Bofona using �hia form, check with your
local Board of Health to determine the form they use, The Syaharn Pumping Record must bosubm\t�eU io
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310CK0R 15351 HOUSE: r on back side rear Ce5 right
A. Facility Information 8UiLD|NG��-+~+�t back side rear left right
DECK: under
Important:When ��
filling OW forms 1 BystemLouotiuni
on the computer,
use only the tab
key to move your xdu�m
ooaor'do nuf
MA
use the return
key, City[Town 2`p^""=
2, System Owner:
IQ 1-1 Q. —------------------- ----------
MA
QtyrTown State Zip Code
B. Pumping Record
3, Component [] Ceeapoo|(a) Septic �� Tight �� Grease Trap
^� ^�
[] Other (describe):
4� Effluent Tee Filter present? Fj Yes No >f yes, was |tcleaned? [-1 Yea Fl No
5. Observed condition of component pumped,
8. System Pumped By.
DoveT|ne
Narne Number
e t8 E t��I
Company
7 Location
,§71gna-fT�ofHauler Date
gnature of Receiving acility(or atlach facility receipt) Date
t5form .doc' 11U2 System Pumping Record ^Page io<1
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