HomeMy WebLinkAboutSeptic Pumping Slip - 826 Johnson - Septic Pumping Slip - 826 JOHNSON STREET 9/23/2024 Commonwealth of Massachusetts
City/Town of
4 System Pumping Record
Form 4
PEP 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 [hey use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from .he pumping date in
accordance with 310 CMR 15.351.
HOUSL front back side rear left right
A. Facility Information RUILDING, front back side rear left right
Important: When DECK: under
illling out iorms 1. System Location:
on the computar, Q
use only the tab
key to move your Address
cursor•do not �- An+ G�1„� _MA
use the return CII ITown
key. Y Slate Zip Code
2, Systern Owner:
Name
MR
nrun
Address (li different from location)
_ MA _
CIlyfTown _ Stale Zip Code
"66 . S ?_'3 _072j
Telephone Number
B. Pumping Record ��
1, Date of Pumping Dal - -- ... - 2. Quantity Pumped: 5
Gaflons
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 condid6n of component purnped:
6. System Pgrn,ped By:
Have Tiney Mass 1AA95 Mass 1AD31Z
Hama Vehicle License t ber
Weson Enterprises, nc,
Company
-_...�—___.._— _
7. ZLIion where contents were disposed:
Signature of Hauler Dale
Signature of Receiving Facility-(of atl ach iacllity(ecelpl) Date
151orm4.fjOc 11112 Syslern Pumping Record Pane 1 of 1