HomeMy WebLinkAboutSeptic Pumping Slip - 1451 Osgood St - 6-6-2024 - Septic Pumping Slip - 1451 OSGOOD STREET 6/6/2024 rOW/7 Of
Commonwealth of Massachu
setts n
City/Town of r�
System Pumping Record 4 22
Firm 4
DEP has provided this form for use by local Boards of Health. Other farms m but the
information must be substantially the same as that provided here. Before using this o ck 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. System Location.
on the computer,
use only the tab ._._.. .
key to move your Address
Cursor-do not
use the return . ._._ ® C A.. ..._... ... ...... .... ..__ . : .. .. ___ __
key, ity/Town State Zip Code
m Owner:2. System �. �.
Name
INn
Address(if different from location)
City/Town State Zip Code
------------ -------------- _.._,.- ---- -----------_..
Telephone Number
B. Pumping Record
1. Date of Pumping ___ 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
_ __. ............. ...
6. System Pumped By:
Name Vehi
cle License Number
r
t ,
Company
7. Location where on nts were disposed:
g -- _ .._............ .........
Si .
nature of aul Date
Signature of Div` cility(or atta ^°feacility receipt) Date
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