HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 132 DUNCAN DRIVE 2/3/2025 Commonwealth of Massachusetts
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System Pumping
Record
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DEP 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 fmrm, 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
0000ndoncewith 310CMR 15.361
HOUSE: front
ft
^ Information
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A. FacilityInformation BUILDING: front buck �/v� rear left right
DECK: under
Important:When �
m|mgout forms 1, System Location:
nn the computer,
use only the tab
key m move your *uumoy
ovwo, do not
MA
use the return
key. ~.,..—. ~~. Z.~ ~.~.
2 System �
W/ 1116 a r�l--U 'Sl(X_
Name
Address(if different from location)
K0A
Oxv/Town State_~ ' Zip Code
i US
-f—elephone Number
B. Pumping Record
1, Date of Pumping 2, Quantity Pumped, I I o ns
3. Component: E Cesspool(s) Septic Tank Tight Tank Grease Trap
4. Effluent Tee Filter present? F] No If yea, was it cleaned? Yea [] No
5. Observed cond't'o of conno � �ump
ed,
G, System PVmped By:
Dave T(n
Name 6Vehlcle Lice ber
9ateson E tB[ ' j
Company
7, Location where contents were disposed:
Signature of Hauler Date
t5fom4dou 11/12 System Pumping Record 'Page I of