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HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1180 TURNPIKE STREET 5/8/2025 Commonwealth of Massachusetts, Town of North 4n C ity/Town of AAY/1,A An el 6)L.,,e.-r dWer System Pumping Record Form 4 MAY 5 2025 DEP has provided this form for use by local Boards of Health. Oth ggjaVbe used, but the information must be substantially the same as that providedIBe�o 11 IqpWj eck with your local Board of Health to determine the form they use. The System Pumping Record mul(04tmitted 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 Ad ress cursor-do not use the return ......... key. .Aty -own State Zip Code 2. System Owner: VQ Name ............------------------------ Address(if different from location) State -1 a — t c V Telephone Number B. Pumping Record 1. Date of Pumping D 2. Quantity Pumped ate ons 3. Component: ❑ Cesspool(s) septic Tank El Tight Tank F1 Grease Trap Ej Other(describe): 4. Effluent Tee Filter present? [:] Yes No If yes, was it cleaned? ❑ Yes n No 5. Observed condition of component pumped: --611-11--' &�twll) cl 6. §0jern Pumped By: /--7 -- ----------------------------------- ............ A0 Name Vehicle License Number fCo m pa ny 7. Location where contents were disposed: Q/N/i Sig -------------- ——---------------------------- --n-a--tu.r of auler Date Signature of Re acil facility receipt) Date t5form4.doc-11/12 System Pumping Record-Page 1 of 1