HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 915 JOHNSON STREET 4/22/2024 Commonwealth of Massachusetts
City/Town of doh Av)ck�le4l'_
System Pumping Record APR 2 2 2024
Form 4
M
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, q 15 "�o1�Y1SG►"1 ' Artie t
use only the tab
key to move your Address cursor-do not A/,;!4t, Andw;e r MA OALIS
use the return City/Town State Zip C de
key.
2. System Owner:
�,ein I-14-N e5
Name
Address(if different from location)
Cityrrown State Zip Code
G-7 u`I vy
Telephone Number
B. Pumping Record
3/1 '2 --J ICc �
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [�/No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By: ` 1
Name Vehicle License Number
—T;r~, (91Mt !W P"6eg W+►l)g
Company
7. Location where contents were disposed:
Si �turfeHau�ie Date
Signature of eceiving Facility(or attach facility receipt) Date
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