HomeMy WebLinkAbout2 - Septic Tank - Septic Pumping Slip - 1292 OSGOOD STREET 1/11/2022 Commonwealth of Massachusetts %jeoviED
City/Town of ,p,N 112022
System Pumping Record ANDO�ER
Form 4 tOWN OH EPA TMENT
A VOLT
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 computer, '� ';�/d
use only the tab
key to move your Address
cursor-return
not I / N Xr ✓U �
use the turn lsGL1 ' r ..
key. City/Town State Zip Code
2. System Owner:
r
Name
Address(if different from location)
City/Town State Zip Code
s 7 0/ - 3IFJF S—
Telephone Number
B. Pumping Record
�1. Date of Pumping I I 2. Quantity Pumped: �, ,S7J
Date Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ( — i S0U S Op
4. Effluent Tee Filter present? ❑ Yes Ej No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
HCqu 'e C,
6. System Pumped By: S
Name Vehicle License Number
Company
7. Location where contents were disposed:
P4 ✓� � //
Signature oPWuler Date
Signature of Receiving Facility(or attach facility receipt) Date
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