HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 97 COMMERCE WAY 10/16/2025 r i
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System Pumping Record �10CT 16 2025
Form 4 I
DEP has provided this form for use by local Boards of > , t�r#ri tri 'y be u�s"ed', but,the
information must be substantially the same as that provided ere. Before using this form, check with your
Iocal Board of Health to determine the form they rise, The System Pumping Record must be submNd to
the local Board of Health or other approving authority within 1 days from the pumping date in
accordance with 310 CMR 15.251-
1,
,A,. Facility information
Important When
filing out forms I. System Location:
use computer,
only the tab °
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"; f"�
key move your our Address
cursor-do not
use the return
key. Gcty!lown 5tzte i Zip Code
2. System Owner w "i
Name
Address(If different from location)
ciiy/Town State ;Zip Code
Telephdne Number
B. Pumping Record i
tN) C t V Pumped:
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1, bate of Pumping Date . Quan 'fty mped.2 ;I �Sallons'
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3. Component; 7 Cesspool(s) Septic Tank ❑ Tight Tank Grease Trap
j7 Other(describe):
4. Effluent Tee Filter present? ❑ Yes E! No If yes, has it cleaned? LJ Yes '❑ No
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5, Observed condition of component pumped,
6...tc .,...t
j
y 6. System Pumped By;
!~dame Vehicle Uicense Number
Wayne's Drains, Inc.
Company
W j
7. Location where contents were disposed;
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Signature of Mauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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