HomeMy WebLinkAboutSeptic Pumping Slip - 469 BOSTON STREET 5/18/2007 � 3
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DEP has this form for use b local Boards of Health. The st°e . ... d°°arid ust
be submit#ed'to the local Board of Health or other approving autho itye
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A, Facllity Information
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only the tab key Address
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use the retum tyRown State
Zlp Code
y 2 System t�wner,
• �' "r Name ' � + I
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""' Address(if different from location)
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City/Town
State Code
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Telephone Number
1 g `Pumping Record
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«� Data of Pumping Date 2. Quantity Pumped:
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Gallons
3, 'Type of system. ® Cesspool($) Septic Tank ❑ Tight Tank
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Other(describe)
Effluent Tee Filter present?.,❑ Yes o If yes, was It cleaned? ❑ Yes No
+Condition of Syst m:"'
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row
$ Sy Pumped
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1' f Vehicle License Number
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Location where contents Werg disposed;
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httpJ/www mass'.gov/deplwafer/approvafs/t6form$,htm#Inspect
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