HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 226 ABBOTT STREET 6/6/2024 of
Commonwealth of Massachusetts c ��
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City/Town of " °ter " FE9
- System Pumping Record 2025
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DEP has provided this form for use by local Boards of Health. Other forms may be used,
information must be substantially the same as that provided here. Before using this form, checc ith 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 . .. --- _..._...
key to move your Address
cursor-do not
use the return
key. `City/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 Daq - .-------''._....______...._.._...._._ 2. Quantity Pumped: Gallons_...__ -...-
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe); _.-__ _. _ _ ______.. _.
4. Effluent Tee Filter present? ❑ Ye No If yes,was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
- -
y Pumped By:6. System
...._.... --------------- _._._ _......_..__....._-_
Name Vehicle License Number
Compan
7. Location where contents were disposed:
_— .... _..------------ -
Sig r of er Date
.......
Signat eiving cility(or attach facility receipt) Date
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