HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 21 APPLETON STREET 7/9/2024 Commonwealth of Massachusetts Town of lVorth MdOver
City/Town of 05
rc system Pumping Record
Health
Farm 4
LIEF' has provided this form for use by local Boards of Health. Other farms 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 to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.31.
A. Facility Information
Important:when
filling out forms 1. System Location:
on the computer, ee�
use only the tab s _. I _ 4
key to move your Address
cursor-do not i
use the return '
key. C�ty(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: [-1 Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? n Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condtion of component pumped:
6. System Pumped By:
.. �` .
Name yr f a Vehicle License Number
6
Company
7. Location contents were disposed:
_ ---------- _..__ ----..__...-
...... ....
Sign ur f Mauler _. Date
- __ _.. _...__ .._._. _ _......._.m ......... -----..__..
Signature o ing Facility(or attach facility receipt) Date
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