HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 843 JOHNSON STREET 1/2/2024 Commonwealth o`h�ss�h�tts
City/Town of 10 ,PN
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, / cJ0 y1
use only the tab
key to move your Address
cursor-do not
use the return key. City/Town State Zip Code
2. System Owner:
_VE�ck L Sa)P
N e
ntrn
Address(if different from location)
City/Town State Zip Code
7Y 3,5' R V_ 8- c( -7
—
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed con ition of component pumped:
n�
6. System Pumped By: �; a� ( z
�TL � M V
Name , Vghicle License Number
C�
Company 11
7. Location where contents were disposed:
C,� s
Signature o au r Date
Signature of Rec 'vin F i or attach facility receipt) Date
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