HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 35 TURTLE LANE 12/13/2024 [~Omm[}[lwea|fh of Massachusetts
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S y s te m Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health, Other forms may be used, but the
information must be substantially the name as that provided here, Before using [his form, check with your
local Board of Health Uz determine the form they use, The 8yeham Pumping Record must be submitted Lo
the local Board of Health or other approving authority within 14 days from the pumping dote in
accordance with 310 CK8R 15.351
HOUSE: front back ide ',rear left (!4113T
A. Facility InformationBU|LD(NG� front back src � raar left right
DECK: under
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on the computer,
use only the tab —35-2-vrll
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2, System Owner
Ad�ress(if different from location)
K8A
CityfTown
-t�lephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped,
3. Component: Cesspool(s) Septic Tank Tight Tank Grease Trap
[] Other (describe):
4, Effluent Tee Filter present? Yem4��� No If yes, was it cleaned? Wq Yee [] No
y�
5, O di n of
6. System Pumped By:
Dave Tln1AA95E a s s:1A]DZ3�1Z)
Name Vehlcle License
eateson E te[ Inc,
Company
7, 1
ationh disposed: