HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1029 JOHNSON STREET 9/5/2019 � Commonwealth of MassachusettsRECEIVED
,1 r City/Town of r Q19
i`System Pum in low �►oEp "w
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DEP has provided this form for use by local Boards of Health. Other forms May be
information must be substantially the same as that provided here. Before using this for
local Board of Health to determine the form they use.The System Pumping y used, but the
the local Board of Health or o In
g date In
'Other approving authority within 14 days from the Pumpm, check with your
accordance with 310 CMR 15.351, p 9 Record must be submitted to
A. Facility information
Important:When
filling out forms I. System Location:
on the computer,
use only the tab G G�
key to move your Address S h .
cursor-do not r f
use the return �-
key. city;;own
Q2. System Owner: zip code
Name z)
Address(if
different from location)
State c Zip Code
�7O
Teler`' n tJumcer ` �� ( 9
B, Pumping
Record
1. Date of Pumping ' `L
c
Date 2. Quantity Pumped:
3. Component: Gallons
❑ Cesspool(s) ❑� Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No
If yes, was It cleaned? ❑ yes [] No
5. Observed condition of component pumped:
6. System Pumped By:
pm& Drain Co.,Inc. Vehic- le Lloense Num' bey 5 Hallberg park
Company ,
7. Location where contents were disposed:
r"
{
Signature of Hauler
Date
Signature of Receiving Facility(or attach fac111ty receipt) Data
t5form4.doc-11/12
System Pumping Record•Page 1 of 1