HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 997 DALE STREET 4/22/2024 Commonwealth of Massachusetts -� ,��
City/Town of M(-Vh AOdwer
System Pumping Record o24
APR 222
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, ('1n 1`
., De{p
use only the tab V1"1 J"1
key to move your Address 'w � ,
cursor-do not A�OC i�c,��o�J'�r AAA 61VA S
use the return
key. Citylfown State Zip Code
2. System Owner:
66 n o n
Name
hTJ^,1
Address(if different from location)
City/Town State Zip Code
q�Zx ,(.pgq—Ysa Z
Telephone Number
B. Pumping Record
1. Date of Pumping 3 14 2 2. Quantity Pumped: (fib
Date Gallons
3. Component: ❑ Cesspool(s) [9/Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [�/No If yes, was it cleaned? ❑ Yes dNo
5. Observed condition of component pumped:
6. System Pumped By:
'�.AJ(D
Name
11r�1 1 Vehicle License Number
''kmv�•' ��1, �i .56� Q1�uWdlnti AC2Fi�l��
Company
7. Location where contents were disposed:
l�
Signature f ler Date
Signature of Receiving Facility(or attach facility receipt) Date
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