HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1001 JOHNSON STREET 8/4/2021 Commonwealth of Massachusetts `v�0
City/Town of R�G�
System Pumping Record G 0 42011
Form 4 P� R
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DEP has provided this form for use by local Boards of Health. Other forms 9=121 ed, 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.
A. Facility Information
Important:When.. -�
filling out forms 1. System Location:
on the computer,
use only the tab fop ! n j.n SO V S{-
key to move your Address
cursor- riot /OUP,
use the return City/Town n !/
key. � State Zip Code
2. System Owner:
U r-
-AName
rin
Address(if different from location)
City/Town State Zip Code
SOS- 36S - -71, vy
Telephone Number
B. Pumping Record
1. Date of Pumping 7_ a -2/ 2. Quantity Pumped: (�jGO
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes �Z No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
�rC,t 1C�
6. System Pumped By:
Name Vehicle License Number
�s+ C 7-e
Company
7. Location where contents were disposed:
t-S D
Signature of Ha er Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
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