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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 557 BOXFORD STREET 11/22/2021 _ Commonwealth of Massachusetts RECEIVE© �1 City/Town of __hLAndo\/t►' h R - System Pumping Record ANUOVEA Y p 9 y4 r Form 4 TO ' 14DE���h` ` t 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. A. Facility Information Important:When filling out forms 1. System Location: on the he tabcomputer, r r-- 7 n _� Q r _I S± use only the tab 'Z�/L' (J o key to move your Address cursor- not . A �� n v MA 0 1 lg _1 use the return urn key. City/Town State Zip Code d--1 2. System Owner: Y%_A M o J LA-:S+-i*n Name rrun Address(if different from location) City/Town State Zip Code q-78 - Sad- Telephone Number B. Pumping Record 1. Date of Pumping -- ��� — — 2. Quantity Pumped: 1000 Date Gallons 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: — _ Good 6. System Pumped By: Jan o o rc k .2193 R Name Service Pumping&Dndn Co.,10. Vehicle License Number 5 HObergPatk Company North Reading, 01864 7. Location where contents were disposed: i S SignaturkfHauI7�' �� Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1