HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 21 EASY STREET 3/24/2025 Commonwealth of Massachusetts
City/Town of ,^�/��
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System Pumping Record `' � � �� .
Form �u�>
DEP has provided this form for use by local Boards of Health. Other ��
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information must be nubotantiaUytho name as that provided here. Before usingihia for—.-` ur
iDCg| Board of Health tO determine the hJ[r0 they use, The System Pumping Record must be »ub-"| i0
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310CW1R 16.351
___. `�__� back side rear left -~_~
A. Fac'|'h/ !nfOrNOaf'(]n BUILDING: front bock side rear left right
Important: DECK: under
�wno �
o\llng out forms 1 System Locstim
on the computer,
use only the tab
key to move you, /duress \
cursor'donot
use the returnMA
key, CityfTown =°= Zip Cvnv
10/Q,—] 2. System Owner
Name
Address(if different from location)
MA
City[Tvwn
State Zip Code
-f�-Iephone Number
1, Date of Pumping 2. Quantity Plumped.
D all Gallons
3. Component: [] Cesspool(s) Septic Tank Tight Tank Cl Grease Trap
�7 Other (describe):
4, Effluent Tee Filter present? El Yes No If yes, was it cleaned? El Yea Fl No
5. Observed condition of component pumped,
G, System Pumped By:
Oove T|n
Name Vehlcle License
ea�escn Enfqrprlses, Inc.__
Company
7, Location h re contents were disposed:
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