HomeMy WebLinkAboutDominics Diner Septic Pumping Slip - Grease Food Trappers - Septic Pumping Slip - 492 SUTTON STREET 12/19/2024 If\ Commonwealth of Massachusetts
City/Town of PC Lik A r\&oe.,r
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 CIVIR IS.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab Li q S 0 46 t\ 5
key to move your Address
cursor-do not
use the return — A)Oi(+V\............. D My
key. City/Town State Zip Code
2. Syst Owner:
.......... ... 5 D
Name
-Ad—dress(Wai from io-cation)
CityfTown State Zip Code
B. Pumping Record Telephone Number
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: E] Cesspool(s) E] Septic Tank n Tight Tank Grease Trap
E] Other(describe):
4. Effluent Tee Filter present? M Yes No If yes,was it cleaned? R Yes E] No
Lix
5. Observed condition of component pumped:
—",................. ................
6. System Pumped By:
Name Vehicle License Number
ompany
7. Location where contents were disposed:
..........L ......................
-i�S(g � e of Hauler
Date
—........... ..........
Signature of Receiving FaeNty(or attach facility receipt) Date
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