HomeMy WebLinkAboutTight Tank - Septic Pumping Slip - 203 BOXFORD STREET 10/5/2023 N�
Commonwealth of Massachusetts
City/Town of
1R� - System Pumping Record
Form 4
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 �;1
key to move your Address
cursor not return
use the return City/Town State key. Zip Code
2. System Owner:
rat
Name
I
r:sm
Address(if different from location)
City/Town State Zip Code
�6C"�
Telephone Number
B. Pumping Record
1. Date of Pumping 3 Date, _ 2• Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank 2Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter presen .�YesNo_ If yes, was it cleaned? Yes No
5. Observed condition of component pumped: _.
6. System Pumped By:
Name .�• Vehicle License Number
zz
Company r
7. Location where ontents were disposed:
Gr I/CC 'r
Signature of Hauer Date
Signature of Receiving Facility(or attach facility receipt) Date
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