HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 171 FOREST STREET 5/2/2024 rotv
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Commonwealth of Massachusetts
City/Town of
uSystem Pumping Record
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Farm 4
" 41C
DEP has provided this form for use by local Boards of Health. Other forms may be used, but thee
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 15.351.
A. Facility Information
Important:When
filling out farms 1. System Location:
on the computer, L,
use only the tab
..w . . ...... ... ....... _.. ._-_
key to move your Address
cursor-do not NP of
use the return __ _ _ _ ._.__ ._....... _., _. . -.._
Sta e Zip Cade
key. City/Town
2. System Owner:
� —
Name
as
Address(if different from location)
CitylTawn Mate Zip Code
Telephone Number
B. bumping RecordWAD
. e
I. Date of Pumping G
2. Quantity Pumped: _allo.,..
Date ns
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 con 'tion of component pumped:
6. System Pumped By: 6
_- _._-- - -_ . _
Name Vehicle License Number
! .-
ompany
7. Location here c ntents were disposed:
�.
Signature of r Date
__ ...,...,.... _......_.....
Signature of e eivi Facility(or a ch facility receipt) Date
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