HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 114 BOXFORD STREET 1/2/2024 Commonwealth of Massachusetts
City/Town of A( M *Z(& . NJ
System Pumping Record 1N
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, "
I 1 t ,t1� v� _�A
use only the tab l f �/' w�J
key to move your Address
cursor- not 44?41 K[„ A&0 Life—
key.
use the return City/Town State Zip Code
2. System Owner:
Name
Irmo
Address(if different from location)
City/Town State CI-7 8 _ 7p Coo
Telephone Number L1
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) LJ 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:
(9L;"D j
6. System Pumped By:
Name Vehicle License Number
Compan
7. Location where co nts were disposed:
ISignaturof HtivinF
Date
Signature of R ity(or ch facility receipt) Date
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