HomeMy WebLinkAboutSeptic Pumping Slip - 1794 Salem St - 10-24-24 - Septic Pumping Slip - 1794 SALEM STREET 10/24/2024 Commonwealth m� Massachusetts
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System Pumping
Record
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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 ae that provided hero. Before using this form, check with your
local Board of Health tudetermine 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 31OCK8R15.3S1.
A. Facility Information
Important:When
filling out forms 1� System Locationi
on the computer,
use only the tab
key m move your ^oomea
cursor do not
use the return
key. City/Town State Zip Code
_ System Owner:
Name
Address(if different from location)
No Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Pump'ng Record
1. Date of Pumping Date 2. Quantity Pumped: awrrs
3 Component: � �e�p�|�) Septic �� -�N�nk � Grease Trap
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[] Other(describe):
4. Effluent Tee Filter present? D Yes VNo |f yes, was itcleaned? Yes No
5. Observed conditionofoomponent � d
G. System Pumped By:
Name 1-14L� Vehicle License Number
Stewart's Septic 58 So Kimball St 8radfnr MA
Company
7. Location where contents were disposed:
Signature of aler Date
Signature of Receiving Facility(or attachfw�kity receipt) Date ___
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