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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1631 SALEM STREET 1/2/2024 Commonwealth of Ma saphusetts of City/Town �/ LPN ti System Pumping Record Form 4 Up- - 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 /1 i2 —►�'in�T-��! �� C key. b� City/Town State Zip Code 2. System Owner: .—� 1 4)'-\ Name recta Address(if different from location) Cityrrown State Zip Code 7 7 � � Telephone Number B. Pumping Record �_ ) 1 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) [D/Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: b V Cb' ( 6. System Pumped By: Name r Ve i le License Number Company 7. Location where ontents were disposed: Signature of uler Date Signature of roing Facility(or attach facility receipt) Date i t5form4.doc•11/12 System Pumping Record•Page 1 of 1