HomeMy WebLinkAboutSeptic Pumping Slip - 4-18-2024 - Septic Pumping Slip - 173 RALEIGH TAVERN LANE 4/18/2024 Town of North
Commonwealth of Massachusetts nd®V r
City/Town of I Q .
n System Pumping Record
Farm 4
Oep
DEP has provided this farm for use by local Boards of Health. Other forms maC1y Aftbut the
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. System Location: ^� rt
on the computer, ..t rI ACJ✓a� '!
use only the tab A
key to move your Addres
cursor-do not C
use the return ___ ___...
key. ity/Town _. State Zip Code
2. System Owner:
.(--.. .._. b +
er-
Name
Address(if different from location)
City/Town State Zip Code�
---
Telephone Number
B. Pumping Record Lill /zq
1. Date of Pumping G
2. Quantity Pumped: -----__allo__. _
Date ns
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? F-1 Yes Q No
5. Observed condition of component pumped:
6. §yslem Pumped By:
..... ._ _
Vehicle License Number
Name
Company
7. Location whe contents were disposed:
_ _.------.
t
Signa Date
Signang Facility(or,"ttach facility receipt) Date
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