HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 115 CRICKET LANE 6/5/2026 Commonwealth of Massachusetts
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City/Town of
System Plumping Record 9zoz L - in
Farm 4
DEP has provided this form for use by local Boards of Health. Oth e se but the
information must be substantially the same as that provided here. l fMik with yet:
local Board of Health to determine the form they use.The System Pumping Record roust be submitted t(
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance With 310 Gft 15.351.
A. Facility information
Important:When
filling out farms 1. System Location
on the computer, �
use only the tab / t' r ''
key o move do not
Address
cursor
use the return City/Town State Zip Code
key.
VQ 2. System Owner: fa
game
Address(if different from location) .__..—
_ State Zip Code
Cityf'T'ow�rn
Telephone!Number
B. Plumping Record
Callon
._ � . ...
1. bate of Pumping o �—� 2, Quantity Pumped: �--
3, Component, [j Cesspool(s) (.w( Septic Tank .m Tight Tank Q Grease Trap
Other(describe):
4. Effluent Tee Filter present? [I es ..No)�, if yes,was it cleaned? 0 Yes Elo
5. Observed condition of component pit %ped:
6. System Pumped By:
Vehicle License Number
Name t
�ocnpany
7. Location wwh re contents were disposed:
Signature of l-lau ez_ —
ee
Crate
Signature of Receiving Facility(or attach facility receipt)
System Pumping Record!Page 1
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