HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 491 SALEM STREET 3/24/2025 [`[]mm[)[]wea|fh of Massachusetts
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��ys+e�� Pumping Record
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DEP has provided this form for use by local Boards of Health. Other forms nay
-lo�c, used, but the
information must be substantially the same as that provide d j&fore using this form, check with your
local Board of Health hz determine the form they use, The S ��� must be submitted ko
the local Board of Health or other approving authority within 14 days from� �LWtein
oocordanoevvith 31OC��R 15,351
HOUSE: front bac� side rear (e f Dtr i p,h t
E 31
A. Facility Information BUILDING: front(back side rear \e+ right
Important:
under
ant��hao �
NlIng out forms 1 System Loostion�
oo the,ompuE)f,
use only the mo
key to move your Address
cursor'uo not
MA
use the return
Key. ~^' `-^ "`a`" Zip C"=
2. System Owner,
e3 en
Address(if different from location)
MA
City/Town late Zip Code
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ephone Number
B. Pumping Record
1, Date of Pumping 2. Quantity Pumped,
Date Gallons
3, Component: Cesspocl(s) Septic Tank Tight Tank Grease Trap
[] D(her (desohhe)�
4, Effluent Tee Filter present? Yee E] No If yem, was it cleaned? Yea F] No
5, Observed condition of oom onent purnped,
8, System Pumped By:
Name Vehicle License Nu
Omve T|n
D t8 Inc.
--------'
Company
T oc tion where contents were disposed:
'§ignature of
Hauler Date
-�-I�t—ure-�f fig acility(or attach facility receipt) Date
t5fnnn4.dnu' 11A2 System Pumping Record 'Page 1u(1