HomeMy WebLinkAboutSeptic Pumping Slip - 4-23-2024 - Septic Pumping Slip - 121 OLD CART WAY 4/23/2024 Town Of o
Commonwealth of Massachusetts rth noVor
City/Town of FE8
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02,5
System Pumping Record
Form 4 / / e oc
DEP has provided this form for use by local Boards of Health. Other forms may be the
information must be substantially the same as that provided here. Before using this form, c eck 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, ww t
use only the tab ---
key to move your A less
cursor-do not
use the return -. _. . __.._ _ __._.. _..._ _._. _...
key. City(Town State Zip Code
VQ 2, Sy tem Owner:
0 .
_ __ _ __ ,....
Name
Address(if different from location)
City[Town State C de
_ - --
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: It11
Date caaons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Ye No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed co dition of component pumped:
6. Sys em Pumped By: gg {per
N me {y}} .. Vehicle License Number
ypN,umber
Company
7. Location where t nts were disposed:
Signature of H le pate
Signature of _e gaoltttyor attach facility receipt) Date
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