HomeMy WebLinkAboutSeptic Pumping Slip - 1010 Johnson St - Septic Pumping Slip - 1010 JOHNSON STREET 9/12/2024 Commonwealth of Massachusetts
City/Town of
J: 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 you
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 15.351.
A. Facility information
Important;When
filling out forms 'System LO"68'tion:
on the computer, —Z
use only the tab A
---
key to move your Address
cursor-do not
use the return
key. Cityl-rown state
Z System Owner: Tip Cooe�
Name
Address(if different from location)
Ciiyf own _State Zip
—Code -
B. Pumping Record telephone Number
1. Date Of Pumping Date 9- 2. Quantity Pumped:
Gallons
3. Component: Cesspool(s) Septic Tank F1 Tight Tank n Grease Trap
Other(describe):
4. Effluent Tee Filter pres T! N6_ If Yes, was it cleaned? (P_Y4 n No-� Y Ts�
5. Observed condition of component pumped:
6. System Pumped By:
Name " Vehicle License Number
C—4
Company
T. Location where contents were disposed:
Signature of Hauer Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc-11/12 System Pumping Record-Page 1 of 1