HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1337 SALEM STREET 6/6/2022 �EGE,vEU
Commonwealth of Massachusetts
City/Town of vN p 6101�
System Pumping Record
Form 4 1pWN OWN pEPPaSME
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 C M R 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, -? c
use only the tab Z J -3 7
key to-move your Address
cursor-do not �U ,,/O �
use the return key. City/Town State Zip Code
2. System Owner:
Name
rms
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping S G- 2. Quantity Pumped: rSl<)
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ckgo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed conditiio/onof--co onent pumped:
C c,7
6. System Pumped By:
Name Vehicle License Number
Company
7. Location/where co P
tents were disposed:
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
6
i -