HomeMy WebLinkAboutSeptic Pumping Slip - 404 Salem St - Septic Pumping Slip - 404 SALEM STREET 9/30/2024 Commonwealth m� %� �
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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 bm substantially the same as that provided here. Before using this fonm, check with your
local Board of Health to determine the fnnn they use. The System Pumping Record must be submitted to
the |oom| Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31UCK8R 15.351.
A, Facility Information
Important:When
filling out rvnnu 1. System Location:
on the computer,
use only the tab
key m move your xoneom
curso/-uunm
use the return
key. City/Town State Zip
Code
_ System Owner:
Name
Address(if different ff om location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record MOO
VSV/'�-v'
1. Date of Pumping bate I ( 1 2. Quantity Pumped: Gallons
3. Component: Cesspool(s) WSeptic Tank Tight Tank Grease Trap
0 Other(describe):
��
4. EfUuentTee Filter present? Fl Yea �q No |f yes, was itcleaned? El Yes Fl No
5. Observed condition of component pumped:
6. G
y�steuXm By, a",
Name Vehicle-License Number
Si rt' Septic 58 So Kimball St. Bradford,MA
Company
7. Location where contents were disposed: