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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1001 JOHNSON STREET 8/3/2022 FECE D Commonwealth of Massachusetts 000 City/Town of AUG 0 3 2022 '= System Pumping Record Form 4 TOHEAWN LTH DEPARTMENT F NORTH EFt 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 CM 15.351. A.. Facility Information Important:When filling out forms 1. System Location: on the computer, ,� r use only the tab f©i �(� N y� sa ✓:1 5 key to move your Address curuse the return not �,� //yl /fa,ve-- use the return City/Town frown rr l key. y State Zip Code 2. System Owner: i3n� YYl c�►'► S��v f Name rr:r Address(if different from location) Cityfrown State Zip Code SQL- 3 6: -761 y Telephone Number B. Pumping Record 1. Date of Pumping -7 7—c�g 2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(s) J�' Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes �f Na- If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component puf ped: G�OU 6. System Pumped By: Name Vehicle License Number Company 7. Location where co`�}}tents were disposed: /lG VC Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1