HomeMy WebLinkAboutPump Chamber - Septic Pumping Slip - 30 INNIS STREET 8/23/2023 Commonwealth of Massachusetts
w W City/Town of-�Q(\Aoue.r
System Pumping p� g Record p'L3
Form 4
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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 not
use the return _WC-x kh -�r(-�b0j0-C
key. City/Town ,
State Zip Code
2. System Owner:
en
Name
Address(if different from location)
CitylTown ---_
State Zip Code
B. Pumping Record Telephone Number
1. Date of Pumping 1(2 40-
Date 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank
❑ Tight Tank ❑ Grease Trap
❑ Other(describe): 1 I tiQ r
4. Effluent Tee Filter present? ❑ Yes ❑ No
If yes, was it cleaned? El Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
1'
�a1Pi5aa
Name
Vehicle License Number
Company
7. Location where contents were disposed:
Use der �c.�. re,nce car -}mot
-mot
Signature of Ha er w
Date
Signature of Receiving Facility(or attach facility receipt) Date
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