Loading...
96 Septic Pumping Report 2015 him 171H1- /7 `1(2i Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 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 local Board of Health.to determine the form they use. The System Pumping Record must be submittec to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351, A. Facility Information Important: When filling out 1. System Location: ferns an the compuxr, use only the tab key to move your cursor do not use Fhe return Address' City/Town 2. System Owner. J°J< C FFFC State Zip Code Ime-,f ` Areemwo Address(If different from Iocatlon) Cityrrown State Zip Code Telephone Number B. Pumping Record 6 15 1. Date of Pumping 3. Type of system: 2. Quantity Pumped: 'Ogre Gallons ❑ Cesspoc,l(s) _'Septic Tank ❑ Tight Tank ❑ Grease Trap _ cams 11TYYl :nci ❑ Other(describe): 4. Effluent Tee Filter present Yes No Condition of System: 5. CoeP 6. System ed By: If yes, was it cieaned?tes,❑ No Na S ht. Company 7. ovation where con ---ts were di posed: Vehicle License Number Signature of Haler/ ' nature of Receiving Facility Date Date tfifarm4.dos.03/0e System Pumping Record•Page 1 of 1