HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1337 SALEM STREET 9/19/2023 Commonwealth of Massachusetts
City/Town of �/=-� �dUf P��No�PP
System Pumping RecordForm 4
NE 19tioti�
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 rnove your Address
cursor-do not
use the return City/Town
key. y State Zip Code
' 2. System Owner: I
Name v l {
r:ra
Address(if different from location)
City/Town State Zip Code
92%-
T lee phone Number —'
B. Pumping Record
1. Date of Pumping C6^/ ( 2 2. Quantity Pumped:
r
Date —/ Gallons
3. Component: ❑ Cesspool(s) P Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By: Z�b� ? �
-11 v�
Name Vehicle License Number
Company
7. Location where contents were disposed:
V(f
Signature of Hauer Date
Signature of Receiving Facility(or attach facility receipt) Date
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