HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1190 SALEM STREET 4/8/2024 ndo�eC
Commonwealth of Massachusetts
City/Town of
System Pumping Record
0 Form 4 F
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, l
use only the tab �—
key to move your Address
cursor-do not
kuse ey,the return City/Town r / State�v`
Zip Code
2. System Owner:
2 c PG, •
Name
",-
Address(if different from location)
City/Town State
Zip Code
7�1I - 3 7 —
Telephone Number
-B. Pumping Record
1. Date of Pumping 3 l `� 1011 )
p g Date 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) �Z'Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe).-
4. Effluent Tee Filter present? ❑ Ye No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component.pumped:
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where co tents were disposed:
Signature of Hauer Date
Signature of Receiving Facility(or attach facility receipt) Date
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