HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1010 JOHNSON STREET 8/2/2023 Commonwealth of Mass j �A I o
achusettS -�H O
City/ "own of
SYst9m PaaMpIng Record AEG o� �t�la
Foram 4
DEP has provided this form for use by local Boards of Health. Other forms may be used
information must be substantially the same as that provided here. Before usingthis ' but the
local Board of Health to determine the form they use.The System Pumping Rcord must be'su with your
the local Board of Health or other approving authority.
e submitted to
Important.
When ritiing out I- -System Location:
forms on the "W :
computer,use '4
only the tab key Address r S ' S�n S
to move.your
cursor-do not /I/
use the return City/Town1'!)le
key. " State Zip Code
2• Sys#ern Owner:r
ttb
`r
sj R
!! Name ✓+ f IL
C
QAddress(Ifdifferentfrom iocatlon)
Clly/Town
State Zip Code
7,X— 33 yU
Telephone Number
�. P9.ImP,g79 RecoPd
1. Date of Pumping 7-,20 a3
Date 2. Quantity Pumped: ZJ�
3. Type of system: Gallons
❑ Cesspools) Septic Tan ' ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter presen . �Y6 ❑ No if yes, was it cleaned
u.� re ❑5. Condition of System: No a. �--
6. System Pumped By: r-
Name
Vehicle License Number
Company
7. Location where cgntents were disposed:
1 i9�A
ignature oPmauier Date
t5form4.doc•06103
System Pumping Record•Page 1 of 1
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