HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 82 LIBERTY STREET 4/22/2026 Commonwealth of Massachusetts TOw" of Nofth over
City/Town of MAY - 4 2026
System Pumping Record
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DEP has provided this form,for use,by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that Provided here. Before using this form, check with your
the local Board of Health or other approving co 0
local Board of Health to determine the form they use. The System Pumping Record must be submitted t
accordance with 310 CMR 15.35 1. proving authority within 14 days from the Pumping date in
A. Facility information
Important.'When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your jGdas �'-' '
cursor-do not
use the return
key, c _r
2. System Owner State `ii—P—Code
----
Name
Address(if different from Location)
City/Town -
S-t�ate —
Telephone
Numbar
ramping record
1. Date Of Pumping
Date 2. Quantity Pumped:
3. Component: Gallons
0 Other(describe):r" Cesspool(s) Septic Tank 0 right Tank El Grease Trap
4. Effluent Tee Filter present? El Yes 0 No If yes,was it cleaned? 0 Yes 0 No
& Observed condition Of component Pumped:
6. System Pumped By:
—Vehf�deUcen�aeN'�'mb�er ����
Company
7. Location where contents were disposed:
2.
Sign nr f Hauler
Signature of Receiving Facilityor attach facility receipt)
iiifitv�remi-fi I
Crate
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