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HomeMy WebLinkAboutSeptic Pumping Slip - 10/3/2024 - Septic Pumping Slip - 42 JERAD PLACE 10/3/2024 Town of IVOrth K� Commonwealth of Mass chusetts dove City/Town of (M 202 System Pumping Record Form 4 Health DEP has provided this farm for use by local Boards of Health.Other farms may be us orow 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. A. Facility information Important:when filling out forms 1. S stem Location: ►( on the computer, ._t �!° ....-._.. __ use only the tab - key to move your Address cursor-do not _.-- __...,._.. ._.._ State Zip Cade use the return Ci /Town key. 2. Syysjgrq Owner: no_ .... Name Address(if different from location) State Zip Code City/Town Telephone Number B. Pumping Record two «� 2. QuantityPumped- 1. — ©ate of Pumping Date Gal{ans [� eptic Tank [� Tight Tank ❑ Grease Trap 3. Component: Cesspool(s) ❑ Other(describe): _ _._ _.__.... 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed coodition of component pumped 6. System Pumped By: ,gyp -- -_- V heals license Number rName 36 fC�ompany� - 7. Location w r contents were disposed: Signature _ Date of atrtaa k Si nature of Re rdiiit y _ g Iy(or attach facility receipt) Date System Pumping Record•Page 1 of 1 t5form4.doc•11112