HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 503 BOSTON STREET 10/7/2022 Commonwealth of Massachusetts
City/Town of �E�E�vEv
System Pumping Record ZW
r Form 4 YH IR
0 100\JF
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DEP has provided this form for use by local Boards of Health. Other formst�t Pe oaw,b0he
information must be substantially the same as that provided here. Before usi g 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 L•oCation:
on the computer, SO 3
use only the tab IJ
key to move your Address
cursor-"do not A/C/ A, n la tvIle
use the return City/Town State - Zip Code
key.
2. System Owner:
1 r� w4 n e
Name
Address(if different from location)
City/Town State Zip Code
S 7ff -a?a--- (n.3 7
Telephone Number
B. Pumping Record
1. Date of Pumping Date)r /7_ aZ 2. Quantity Pumped: Gallons 00 0
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes P No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
C'/ co r'-j"�-�
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
W4
-!T� e
Signature of HauleY Date
Signature of Receiving Facility(or attach facility receipt) Date
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