HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 99 MARIAN DRIVE 12/16/2024 IK
[~[}mM7[]nwea|fh of Massachusetts
City/Town [)f
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System Pumping Record
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OEP has provided this form for use by local Boards of Health. Other forms may be used, but 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 in
the |DC21 Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31OCK0R 15351 -
HOUSE: front
`
A. Facility Information BUILDING: front back ' rear left hQh'
� under
Important:When DECK:
filling Out forms 1. SystemLooation�
on the computer.
use un�the tab � `
keyto move your Address
{
cursor'donot �A
use the n�um -- - -
key. `'r'`-' ~`~`~ Zip Code
2, System OwnerI WQ
L_-M
MA
City/Town
,�ip Code
ne Number
B. Pumping Record
1, Date of Pumping 2. Quantity Pumped.
at�� Gallons
3. Component: Cesspool(s) Septic Tank Tight Tank Grease Trap
[] Other (describe):
4� Effluent Tee Filter present? El Yee No If yes, was it cleaned? El Yes Fl No
5, Observed condit' n of component pumped.
G, System Pumped By:
2aveT|n Mass 1AA95E
Name Nu Qber
eate E f�r r�es }M
Company
7. lion where contents were disposed-,
GLS
�ignature of Hauler te
t5fonn4.dmc- 11112 System Pumping Record ^Page I of