HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 66 CROSSBOW LANE 11/18/2025 Commonwealth Of Mass-achusetts
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DEP has provided this form for use by |000| Boards ofHealth. Other 'U
information must be substantially the same as that provided here. Before using thisyour
local Board of Health to determine the form they use, The System Pumping Record must be���entd to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310CK4R 15,351 -----
HOU3E� back side rear }eft'����
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A. Facility Information BUILDING: front back side rear left right
� under
Important:When DECK:
8Nng out forms 1. System Location:
nn the computer,
use only the tab
key m move your pmumao
cursor do nm
use the returnreturnMA
k e-Y. CityfTown Zip Code
2. System Owner:
Name
Address (if different from location)
MA
Ci��o°n � ����� -�----
t ate Zip Code
felephone Number
B. Pumping Record
1, Date of Pumping 2. Quantity Pumped:
Date Gallons
3, Component: Cesspool(s) Septic Tenh Tight Tank Grease Trap
Other (describe): /
4, Effluent Tee Filter present? [] Yea No If yes, was it cleaned? F� Yea 0 No
5. Observed condition of component pumped.
& System PVmped By:
DoveT|n
Babaaon Enterprises, Inc.
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7. J�c�tion where contents were disposed.
-§7jg-nature of Hauler Date
t5fonn4.dm/ 11A2 System Pumping Record 'Paqe1o/l