HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 927 JOHNSON STREET 4/22/2024 Commonwealth of Massachusetts
City/Town of MXA4n
System Pumping Record A'
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 thehe tabcomputer, (1 q ,►}�-y_���� �
use only the tab `-'(Lf
key to move your Ad rasa �^
cursor-do not L) r l ()tf'
use the return City/Town State Zip Code
key.
2. System Owner:
16W S ► roi5
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
�D� 2-
1. Date of Pumping Date I 2. Quantity Pumped: Gallons `
3. Component: ❑ Cesspool(s) �eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): - - -- - -- --
4. Effluent Tee Filter present? ❑ Yes- If yes,was it cleaned? ❑ Yes ❑ No
5. Observed conditipn of component pumped:
6. System Pumped By:NYm
e Vehicle License Number
Company
7. Location wh9fe contents were disposed:
Signature f Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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