HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 440 BOSTON STREET 1/2/2024 (3) Commonwealth of Massachusetts
City/Town ofY�� "`'�
'' -_ System Pumping Record PN� �tio
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, �f � f > 'S4��
use only the tab _Y�(4 4 ✓J�' �
key to move your Address L � �-�_
cursor-do not x/y !/V [A AAjaz _
use the return ity/Town Sfalre Zip Code
key.
2. System Owner:
Name
Address(if different from location) - —
CitylTown State�y 6, �� — code
Telephone/Number
B. Pumping Record q pql ` cob
1. Date of Pumping Date __ 2• Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) I�Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter presenttYes ❑ No If yes, was it cleaned? ZYes ❑ No
5. Observed condition of component pumped:
d
6. System Pumped By:
Name Vehicle License Number
`Ti�t� Q.G,'c��c�. Sa'1 (�lc,u►�b i/�f- �'��,�/
Company
7. Location where c n nts were disposed:
Signat re of Ha er Date
Signature of R Facility(or atta facility receipt) Date
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