HomeMy WebLinkAboutSeptic Pumping Slip - 06-19-2024 - Septic Pumping Slip - 34 ROSEMONT DRIVE 6/19/2024 Commonwealth of Mas
sachusetts rO /7 O
City/Town of r . OV
w System Pumping Record Or
r Form 4 FEB2
5
DEP has provided this form for use by local Boards of Health. Oth ay be used, but the
information must be substantially the same as that provided here. Befo ' form, check with your
local Board of Health to determine the form they use.The System Pumping Rec submitted to
the local Board of Health or other approving authority within 14 days from the pumping
accordance with 310 CMR 15.351,
A. Facility Information _
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab _. .. .__-- --
key to move your Address
cursor-do not
VA
-use the return ---------= —_— � ..------- -. � _ ..._._ ...— --.. _ ----- ._.._.---
use City/Town State Zip Code
r 2. System Owner:
Name
n
Address(if different from location)
--------............. --------..- ---- ._.-.._...._..._..._...- --- -...__...-_..... -----..----------- _._.._._.__..__._.._... --
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ----.............._.__-_.---...._-.._.._.._...____. 2. Quantity Pumped: G
Date- Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed cosdition of component pumped:
boo
_ ----- - - — --
6. SytemPumped By-
ell,
1 -.
Name Vehicle License Number
ompany
7. ocation where contents were disposed:
........ ........... -- --- -- ._. ----
,..,
Sign ure of auler Date
_..__--- ..... ........ --- .._. ._. .........
Signature o eceiving Facility( ttach facility receipt) Date
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