HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 93 SUGARCANE LANE 7/9/2024 Commonwealth of Massachusetts
I City/Town of
� System Plumping Record FED
025
Farm 4 2
DEP has provided this farm for use by local Boards of Health. Ot A ed, but the
information must be substantially the same as that provided here. Before usin tck 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,
_._..........._.......... ..w__._...._.............._ __...._...__.,_ _..__.._.__.._..._.__.___.._____...__..... __....__...__ ._w_._.._._._._._._..._.._.
A. Facility Information
Important:when
filling out forms 1. System Location:
on the computer, { ,„,
use only the tab 4,.. _
key to move your Address
cursor-do not
use the return " _. _.. _ ..._....___._._
key. ity/Town State Zip Code
2. System Owner:
_
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record _
1. Date of Pumping 2, (quantity Pumped:
Date Gallons
3. Component: C] Cesspool(s) e septic Tank ❑ Tight Tank Grease Trap
❑ Other(describe);
4. Effluent Tee Filter present? Yes ❑ No If yes,was it cleaned? R Yes F� No
5. Observed condition of component pumped:
yM m Pumped By:�. System C
Name Ve 11 hicle License 11 Numbe 11 r
Company
"T. Location JH"a
where contents were disposed:
Signat Date
__Signat act i (or attach facility receipt) Date
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