HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 415 SALEM STREET 1/2/2024 Commonwealth of Massachusetts
- ( City/Town of W44^ Ard) rec �tioti�
System Pumping Record LPN
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 �`✓✓ I C
key to move your Address .
cursor-do not ��. �" A
use the return City/Town State Zip Code
key.
2. System Owner:
Name
Address(if different from location)
Cityrrown State Zip Code
U,tZ-73.3 y(eK6
Telephone Number
B. Pumping Record
a / z1/
1. Date of Pumping Date 2• Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) M/Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): - - --- - -
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed co dition of compon nt pumped:
(9vo
6. System Pumped By:
itc
Name Vehicle License Number
Company
7. Lo/cat_ion where co a is were disposed:
V
Signature qmlauler Date
Signature of Receive lity orattich facility receipt) Date
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