HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 207 BOXFORD STREET 8/19/2024 Commonwealth of Massachusetts
City/Town of =
° System Pumping Record
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,
use only the tab
key to move your Address
cursor- not (� � w�
use the return - 1�
key. City/Town _ _
State Zip Code
2. System Owner: 10w V} t� k
li
Name 9 2024
Address if different from location)
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State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ---1-Ld 2. Quantity Pumped: v
Date
alIons
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 conditior of component pumped:
6. System Pumped By:
rl 5 �-
Name
Vehicle License Number
Company —
7. Location wh a contents were disposed:
��L S�
Sign um
of Hauler Date -- —
Signature of Receiving Facility(or attach facility receipt) Date
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