HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 15 SULLIVAN STREET 3/18/2025 Commonwealth of Massachusetts �°~~ �������
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System Pumping Record MAQ � � 7��
Form '' - � �»��
DEphae provided this form for use by local 8ouode of Health,
information must be substantially the same an that provided here, Bnfure'u� &�
�� 4� kwith your
local Board of Health to determine the form they use, The System Pumping Record muet be submitted kz
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31OCK8R 15.351 -
HOUSE: /front)back side rear left righT
A. Facility Information BUILDING: buck side rear left right
DECK under
Important:When ��
m|mQ out forms 1. System L i
on the computer,
use only the tab
key m move your Address
cursor'unnot
MA
use the return il�
key, City/Town^ ="`" Zip Code
4JQ2. System Owner:
n I
Name
Address (if different from location)
MA
OKvfTowo ---
B. Pumping Record
1 Date of Pumping 2. Quantity Pumped,
Gallons
3. Component: [] Cesspool(s) Septic Tank Tight Tank Grease Trap
Other (describe):
4. Effluent Tee Filter present? Fl Yea No If yes, was it cleaned? Yee Fl No
5, Observed condition of component pumped.
8 System P m d B
y � pe y:
DoveTIn
—�ic —a;P —
Name ��Vehlcle Numb
9afeson E f8 ' l
Company
7, nat�ion h disposed:
ure of Hauler
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