HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 3/23/2020 Commonwealth of Massachusetts
-F� City/Town of 4-6,�
�_ r 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 submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351. \o� ? 'I
N
A. Facility Information �ow ���o�PPRZ
Important:When
filling out forms 1. System Location:
on the computer, g
use only the tab �D�' ✓�
key to move your Address
cursor-do not �, �LA?,''-
key the return City/Town State Zip Code
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2. System Owner:
6 �SjS
Name
aerr
Address(if different from location)
City/Town State Zip Code
5'7f-6_C-
Telephone Number
B. Pumping Record
1. Date of Pumping oat z j/ (� 2. Quantity Pumped: Gallons
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3. Component: ❑ 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:
16 zs-D
Name Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hau r Date
Signature of ReceivV Facilihq6r attach facility receipt) Date
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