HomeMy WebLinkAboutGrease Tank - Septic Pumping Slip - 1503 OSGOOD STREET 4/19/2022 _ Commonwealth of MassachusettsE��`v�`
City/Town of
System Pumping Record APR 1 PNo0
Form 4 MEN
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DEP has provided this form for use by local Boards of Health. Other forms' ay 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,
use only the tab /3 03 .5�)(0 ' S t-
key to.move your Address J
cursor-do not N'! �� A n C�O//P l
use the return 2224
key. City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
SO"y - s ri i- 3c)g5
Telephone Number
B. Pumping Record
1. Date of Pumping 3 02 2. Quantity Pumped: ?Gallons
0
Date 3. Component: ❑ Cess ool s
p ( ) ❑ Septic Tank ❑ Tight Taase
❑ 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:
Name Vehicle License Number
Company
7. Location where cont is were disposed:
1716
Signature of Haute Date
Signature of Receiving Facility(or attach facility receipt) Date
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