HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1190 SALEM STREET 4/3/2023 Commonwealth of MassachusettsE���vEo
City/Town of R
System Pumping Record oacHANEi�
Form 4 -TONE 0' C)EFP8
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 // !G 0 SGt le nq S t
key to move your Address
cursor- not
use the return
urn '
key. Cityffown State - Zip Code
2. System Owner:
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Name
r:raa
Address(if different from location)
City/Town State Zip Code
3o7- ioi6
Telephone Number
B. Pumping Record
1. Date of Pumping 3 -`�2 - �2 3 2. Quantity Pumped: 0c)
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes V No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
60cvj CCJYI��i�iliYr
6. System Pumped By:
Name ti• Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauer Date
Signature of Receiving Facility(or attach facility receipt) Date
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