HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 851 JOHNSON STREET 7/26/2022 JU
Commonwealth of Massachusetts r F�oFC 2620�2
City/Town of O�f� 4 14,T&N ORTy
System Pumping Record o�p�R MFOVFR
Form 4 Nr
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.use only the tab
key to move your Address
cursor-do notuse the return key. City frown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State C, Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping - --- 2. Quantity Pumped: ---- ---
Date Gallons
3. Component: ❑ Cesspool(s) 'Ef 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:
-v 0�► -
6. System Pumped By:
Name Vehicle License Number
Service Pumping L Lrai..
Company North Reading,MA(1
7. L cation where 8 �nt�were'disposed:
Signa re of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1