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HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 34 ROSEMONT DRIVE 6/11/2024 _ Commonwealth of Massachusetts ��- City/Town of .. System Pumping Record Zp Farm 4 eel CEP has provided this form for use by local Boards of Health. other forms may be u information must be substantially the same as that provided here. Before using this form, WhUth 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. A. Facility Information Important:when filling out forms 1. System Location: on the computer, use only the tab 3_Q._... "7 ._._.__ _..__._. _--------- key move cursor do noour Address __.__._.�_. usethe return — ........... -- ._..._..... ...._......- — .__...... .... _ ......__._..._._...._... ---........_..._.............. - ------........_.._......-----� key. City/Town State Zip Code VQ 2. SystemOwner: Name 11 Address(if different from location) City6Town State Zip Code Telephone Number B. Pumping Record 1. Cate of Pumping Da--t_te Ga_____ _ 2. Quantity Pumped: ----__ _. .. _. llons 3. Component: ❑ Cesspool(s) Septic Tank © Tight Tank Grease Trap ❑ other(describe): ....... 4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No 5. observed coedit' n of component pumped: .. .. 6 System Pumped By --le'rely14 ........... ..................................... Name _ .w. ._ e a _ 47 /"�� jJ0 �,� � � hide License Number .. l Company 7. Location where contents were disposed: _ ... ........ _. .._..._. . .._..._.._...._.. _..... _.._- _. .....__ _ .._.. ..._.___Si� ture �'PtauLier Date Signature of Re- g adlity(or attach facility receipt) Date t5form4.doc-11112 System Pumping Record-Page 1 of 1