HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 23 FOREST STREET 1/2/2024 Commonwealth of Massachusetts
I�-- City/Town of SNA
- System Pumping Record
w 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, 2� f Z'fj � S
use only the tab
key to move your Address C�
cursor-do not Jy 4 y k Aa6 V/lr—
use the return CitylTown State Zip Code
key.
2. System Owner:
y-&I A--
Name
Address(if different from location)
City/Town State Zip Code
3101
-7
Telephone Number
B. Pumping Record
V-
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? ❑ Yese�No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped
�By:
,� / -7d
Narne ; �'Ve icice I)c�a Number
Company
7. Location where contents were disposed:
Signature('of ule Date
i
Signature of Re � cili attach facility receipt) Date
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